; .;;^ r BRAK3?, 



A 

PRACTICAL SYNOPSIS 

OF 

CUTANEOUS DISEASES, 



FROM THE 



MOST CELEBRATED AUTHORS, 



AND PARTICULARLY 



FROM DOCUMENTS AFFORDED 



CLINICAL LECTURES 



DR. A BIETT, 



PHYSICIAN TO THE HOSPITAL OF ST. LOUIS, PARIS 



/ 



BY A^CAZENAVE, M. D. &c. and K. E. SCHEDEL, M. D. &c. 



TRANSLATED FROM THE FRENCH, WITH_ 

-C0NGtf?!$ 




PHILADELPHIA: 

CAREY, LEA & CAREY— CHESNUT STREET. 



1829. 






E\STERN BISTRICT OF PENNSYLVANIA, to wit: 

BEITREMEMBERED.thatonthesixteentidayofDecembe^nthefifty-ttol 
year of the independence of the United States of America, A. D. 182 8, Carey, 
Lea and Carey of the said district, have deposited in this office the title ot a 
boo" die ri|ht whereof they claim as Proprietors, in the words following, to 
wit* 

« A Practical Synopsis of Cutaneous Diseases, from the most celebrated au- 
thor fnTpSScuLl? from documents afforded by the Cluneal Lectures of Dr. 
Biett Physkian to the Hospital of St. Louis, Paris. By A. Cazenave^ M. D &c. 
and H E 7 Tchedel, M. D. &c. Translated from the French, with Notes.' 

In conformity to the act of the Congress of the United States, entitled, "An 
act for the encouragement of learning, by securing the copies o ^™PJ ^ 
^nV books to the authors and proprietors of such copies, during the times 
£t„ S«S" And also to the act, entitled « An act supplementary to 
therein menuoj encouragement of learning, by securing the co- 

a vfnf mans charts anl books, to the authors and proprietors of such copies 
S^SS— ne^' and extending the benefits thereof to the 
aS of designing, engraving, and etching historical and other prints. 

Clerk of the Eastern District of Pennsylvania, 



SKEHHETT SIXTH STREET, 

PHILADELPHIA. 



INTRODUCTION. 

THERE are no diseases that have been, and still continue 
to be involved in so much obscurity, as those which constitute 
cutaneous pathology. This appears the more extraordinary, as 
there is no part of the system whose phenomena are more readily 
observable, for they manifest themselves in characters constant- 
ly appreciable to the sight, and moreover, are so frequent that 
they are every moment presented to the observation: but is it 
not this very frequency and the facility with which their exist- 
ence is verified, one great cause of the confusion which has 
reigned among this class of diseases? Here, as in many other 
parts of medicine, the multiplicity of facts has only tended to 
encumber the science — can it be otherwise, when the same 
diseases observed at different stages are described as dissimilar 
affections according to the classification to which they were 
subjected, classifications in themselves defective and vicious ; 
or are thrown together without order or any attempt to group 
them. 

To give some idea of the obscurity that has necessarily re- 
sulted from the application of the same term to different dis- 
eases, the word lepra given to a multitude of cutaneous affec- 
tions, has been used for centuries without carrying with it any 
precise meaning. At one time it is a tubercular disease, 
(elephantiasis of the Greeks;) at another, it is an affection 
in which, rigorously speaking, the skin does not participate, 
at least at the commencement, and which is constituted by 
a considerable swelling of the subcutaneous cellular tissue, 
(elephantiasis of the Jlrabs;) now, it is a squamous inflam- 
mation, (dartre furfaracee arrondie,) or even a union of 
different diseases, (eczema, psoriasis, lichen,) which were 
all received in the Leper Hospital in Paris, in the twelfth cen- 
tury, a hospital which, in 1600, or even later, was still devoted 



INTRODUCTION 



to the same purpose. Or to choose a more recent example, 
at the present time what vague ideas are conveyed by the 
word dartre, and yet we find it constantly employed by me- 
dical writers ; they even attempt to define it as if the word 
dartre was not itself devoid of meaning, or signified anything 
more than disease of the skin, or eruption, of which it is a 
synonyme. 

The want of classification, and latterly their faultiness, have 
also powerfully contributed to throw much obscurity on the 
important study of diseases of the skin. Nevertheless, in the 
seventeenth, towards the end of the eighteenth, and com- 
mencement of the nineteenth century, several authors have 
attempted to collect and arrange the various forms under which 
these diseases appear ; they have formed groups of them, and 
somewhat enlightened this important branch of pathology. 
All these classifications may be reduced to three divisions. 

Mercuriali, 1623, Turner, 1736, Jilibert, 1S06.— One to 
which Alibert has attached his name of late years, was intro- 
duced by Mercuriali, and afterwards adopted by Turner. Its 
fundamental principle is to divide the diseases of the skin into 
two great groups, as they manifest themselves on the head or 
body. But this learned professor in adopting these distinc- 
tions, and giving the name of teignes to eruptions on the 
head, and dartres to those of other parts, is not content with 
these primary divisions, he has created species and varieties; 
hence, there was a necessity for distinctive characters. These 
he found either in the products of the inflammation, in its dif- 
ferent states, in differences of form, &c. Thus, if he met 
an eruption, accompanied by a scaly exfoliation, he arranged 
it as dartre squammeuse, adding the term humid, orbicular, 
&c. according as it was habitually attended by an exudation 
of a fluid, or that it assumed the form of a circle or ring. 
Whenever he met with scabs, (croutes,) he grouped this 
disease around a common species to which he gave the name 
of dartre crustacee, &c. Finally, he made a multitude of 
different sections for those diseases which he could not arrange 
in the other orders. Thus, independently of the teignes, of 



INTRODUCTION. 7 

which he described six ; of dartre, of which he admits seven 
species, he also gives the history of the pliques, ephelides, 
cancroides, lepres, plans, icthyoses, syphy tides, scrophules, 
and psorides. This plan, vast as it is, has been skilfully fol- 
lowed up by this learned pathologist, but is far from being 
exempt from censure, and is not perhaps a certain guide in 
studying the cutaneous diseases. In fact, the reproach that has 
been cast on Mercuriali and Turner for having separated iden- 
tical diseases, because they had a different seat is equally ap- 
plicable to Alibert, as he has adopted their distinctions as the 
basis of his plan, and this attack is the better founded, as there 
is not perhaps a single eruption that has so special a seat, 
that it is never to be met with in other parts, and with similar 
characters. But besides, in grouping diseases according to the 
products of the inflammation, this illustrious professor has in- 
curred the risk of uniting dissimilar affections, and separating 
those which are analogous; this, in fact, has happened; we 
find under the generic term of dartre squammeuse, inflamma- 
tions wholly distinct in their elements, in their course, and 
symptoms, and the mode of treatment they require. Certain- 
ly no exact idea can be formed of dartre squammeuse liche- 
noids and dartre squammeuse humide, when they are group- 
ed in a common order, and the same characters assigned to them ; 
in dartre squammeuse humide itself, taken separately, but 
one certain period of inflammation can be seen, which may, 
however, assume different elementary forms, and constitute a 
disease which it is very important to distinguish. On the 
other hand, we find in this classification, eruptions which are 
precisely similar, ranged as different species. Thus the dar- 
tre furfuracee arrondie is so analogous in every respect to 
the dartre squammeuse lichenoids, that it has the same symp- 
toms, follows the same course, requires the same treatment, 
and only differs from the latter in the form of its spots, which 
should at the most constitute a variety. Notwithstanding 
these defects of classification, defects inherent in the subject, 
the work of Alibert is a precious and lasting monument, from 
the light it has contributed to shed on this class of diseases, 



S INTRODUCTION. 

from the energy of his style, and the truth of his descriptions; 
and if we were to attempt to answer the censures bestowed on 
him by a foreign author, we should only point out the history 
he has given us of the dartre rongeante, of the syphilides, 
&c. which attest in the highest degree the merit of this learn- 
ed pathologist. 

Plenck, 1796, Willan, 1798. Another classification pre- 
dicated on a different basis, was established by Plenck, and 
perfected by Willan. The first, rejecting all topographical di- 
vision, classed diseases of the skin by their external charac- 
ters ; but with the true anatomical lesions he arranged the pro- 
ducts of inflammation, and among the fourteen classes he 
adopted, are seen distinct sections based on scabs and ulcers, 
ranged with those constituted of vesicles and pustules, as if 
these ulcers and scabs are not consecutive symptoms, and 
succeed pustules, &c; the consequences were inevitable, that 
of making two or three different affections from the same dis- 
ease, according as it existed in a pustular, crustaceous, or ul- 
cerous state. 

Willan adopted this ground- work, and established a classifi- 
cation, which, if it is not exempt from errors, is at least, in 
the actual condition of our knowledge, that which presents 
the most clearness, precision, and exactness in the study of 
diseases of the skin. He rejected all products of inflammation, 
and only adopted as the characters of his orders, elementary 
lesions strictly speaking, of these he gives eight. 1. Papulae. 
2. Squammae. 3. Exanthemata. 4. Bullae. 5. Vesiculae. 6. 
Pustulae. 7. Tubercula. 8. Maculae. One of these, it is true, 
(Squammae,) is founded on a product of inflammation, rather 
than an elementary lesion; but the characters which consti- 
tute it are so well defined, and belong so exclusively to the 
diseases he has placed in it, that they form as distinct a group 
as the other orders. Hence this classification taken generally 
presents the greatest exactness. But, if we descend to details, 
we perceive that it leaves something to be desired, even with- 
out adverting to the errors which are only vicious applications, 
and do not detract from the utility of the plan, we mean plac- 



INTRODUCTION. 9 

ing purpura in the exanthemata, erysipelas in the bullae, sca- 
bies in the pustular, acne sicosis menti, (mentagre,) in the tu 
bercula. It is singular to find diseases so widely different in 
their nature and course thus associated, because their elemen- 
tary lesions were similar to a certain point ; variola for in- 
stance with impetigo; but nature will not thus lend herself to 
artificial divisions. Thus there is often but a slight shade of 
difference between a vesicle and a pustule; the bulla in Rupia 
approaches in one of its varieties to the phlysaceous pustule of 
Ecthyma. But there are many diseases which cannot be ar- 
ranged in the eight orders of Willan. Purpura for instance, 
is equally dissimilar to the exanthemata as to the squammge or 
vesiculae; lupus is not always a tubercular disease, &c. But 
notwithstanding these imperfections, the classification of Wil- 
lan certainly offers much facility and precision, and this arises 
from its being based on the principles of the diseases them- 
selves; principles which are invariable, and may be always 
recognised at every stage of the eruption. 

Retz, 1790, Derien, 1894, /. Franck, 1821. A third 
classification, which would present many advantages if it were 
only applicable, is that of I. Franck, who, following those of 
Retz and Derien, has divided diseases of the skin into acute 
and chronic. This distinction appears at the first view to be 
natural, and it seems proper to separate Rubeola from Psori- 
asis, Scabies from Prurigo, but on a closer inspection it will 
be perceived that the plan is impracticable. How can we in 
fact divide a work into two parts, in one of which is given 
the description of a disease in an acute form, whilst the ac- 
count of it in a chronic condition is contained in the other, or 
even admit with Franck that such an eruption is always acute, 
and another always chronic; this may be true as regards a few^ 
but is not applicable to the majority, and particularly those 
which this author considers as always being in the latter state. 
Hence these distinctions which are of the highest importance 
in particular description, cannot form the basis of a general 
classification. 



JO INTRODUCTION. 

Such are the three principal methods by which diseases of 
the skin have been arranged. As may be perceived, neither of 
them presents sufficient precision or clearness to preclude our 
wishing for a better; but it is in the very subject matter of 
these classifications that we must look for the cause of their 
imperfections. In fact, this class of diseases is presented to 
us, in characters appreciable by the sight, but the tissues in 
which they have their seat are not yet sufficiently well known 
to enable us to establish precise and durable divisions on them. 
It may be said indeed, that the only classification of diseases 
of the skin, which will be exempt from faults, will be that, 
which has for its base, the special seat of each alimentary le- 
sion, and so long as the anatomy of the dermoid system shall 
remain in its present state, shall we be deficient in a perfect 
classification of the cutaneous affections. 

S Plumbe, 1824. In the actual state of our knowledge, it 
is vain and illusory to attempt to arrange these numerous 
diseases by the causes which produce them. Mr. Plumbe, 
who has adopted this classification in a recent work, has ra- 
ther added new obstacles to those already existing in this 
branch of pathology, if a work undertaken on such a plan 
can exercise any influence on the science. 

We have adapted among these different methods that which 
appeared to us as most favourable to the study of cutaneous 
diseases, and have selected that of Willan, with the modi- 
fications introduced by M. Biett. Wherever the classification 
of Alibert agrees with that of the English pathologist, we 
have endeavoured to present both, and have always at the 
head of each chapter succinctly indicated the principal analo- 
gous divisions admitted by the learned French author. 

We have classed the diseases of the skin, as may be seen by 
the following table, by their external characters, and their ele- 
mentary lesions, referring to as many different chapters, those 
which it appeared to us could not be arranged in any oi the 
eight principal orders. 



INTRODUCTION 



11 



Order in which the Diseases of the Skin are classed and 
described. 



Order T. 



Order II. 



Order III. 



Order IV. 



Exanthemata. 

Erythema. 

Erysipelas. 

Roseola. 

Rubeola. 

Scarlatina. 

Urticaria. 

Vesicul^:. 

Miliaria. 

Varicella. 

Eczema. 

Herpes. 

Scabies. 

Bull^:. 

Pemphigus, 

Rupia. 

Pustulje 

Variola. 

Vaccinia. 

Ecthyma. 

Impetigo. 

Acne. 

Mentagra. 



Order V. 



Order VI. 



Order VII. 



Order VIII. 



Porrigo. 

PAPULiE. 

Lichen. 
Prurigo. 

SQUAMMiE. 

Lepra. 
Psoriasis. 
Pytiriasis. 
Icthyosis. 

TuBERCULA. 

Elephantiasis 
Graecorum. 
Molluscum. 
Framboesia. 
Macule. 
Discolor 'at ions. 
Bronze colour 
Ephelis. 
Noevus. 
Decolorations, 
Albinism. 
Vitiligo. 



Diseases which cannot from their nature he arranged with 

the above. 

Order IX. Lupus. 

Order X. Pellagra. 

Order XI. Syphilitica. 

Order XII. Purpura. 

Order XIII. Elephantiasis of the Arabs. 

Order XIV. Diseases op the Sebaceous Follicles 

Order XV. Keloide 



12 INTRODUCTION. 

The diseases of the skin, as may be seen in the above plan, 
may be generally referred to a certain number of elementary 
lesions. These lesions are constant in all the eruptions of 
each order. In whatever form, at whatever stage, cutaneous 
inflammation is observed, these may be always seen either 
combined or unaltered, but always recognisable with a little 
attention, either on the diseased surface itself or in its imme- 
diate vicinity. All appear with particular characters, all have 
an individuality very important to study, and it is because they 
have been misunderstood that we see the word pimple con- 
stantly employed, a term devoid of precision or meaning, or 
else the word pustule has been applied to a multitude of dif- 
ferent eruptions. 

Exanthematous diseases, (exanthemata.) By this term is 
meant spots of different degrees of redness, of various forms 
and extent, disappearing under the pressure of the finger, and 
terminating by retrocession, resolution, or desquamation. 

Vesicular diseases, (vesiculas.J By vesicles are to be un- 
derstood small elevations of the epidermis, formed by the col- 
lection of a serous and transparent fluid, which, under certain 
circumstances, may become opaque, or even sero-purulent. 
The absorption of the secreted fluid, a slight exfoliation, or 
what is more frequent, excoriations, or small and very thin 
crusts, may succeed to vesicles. 

Bullar diseases, (Bullae. J These diseases only differ from 
the preceding in their size, which is much greater: they are 
small superficial tumours, formed by a serous fluid effused 
under the epidermis. 

Pustular diseases. (Pustulse.) This denomination may be 
exclusively applied to purulent collections, formed on the sur- 
face of an inflamed mucous tissue. The fluid they contain 
gives rise to incrustations of different thicknesses. They leave 
either chronic indurations, ulcerations, or only red inflamed 
surfaces, sometimes slightly excoriated. 

Papular diseases. ( Papulx. J Papulae are well-defined, 
solid, firm elevations, not containing a fluid, only susceptible 



INTRODUCTION. 13 

of ulcerating at their apex, but generally terminating by re- 
solution, or a branny exfoliation. 

Scaly diseases. (Squamae. J By this term is meant scales 
or lamellae of altered cuticle, generally thickened, dry, white, 
and friable, originating from small papular elevations, which 
are more or less red and inflamed. These become de- 
tached and are reproduced for an indefinite time by successive 
exfoliations. 

Tubercular diseases. ( Tuhercula.J By tubercles are to 
be understood, small, hard tumours, more or less elevated, cir- 
cumscribed and permanent, which may ulcerate at their sum- 
mit and partially suppurate. Tubercles are here considered as 
primary diseases, and not having been preceded by any puru- 
lent collection. 

Spots. (Maculae. J Maculae are permanent discolora- 
tions or decolorations of either a part or of the whole of the 
skin, and which are uncombined with any general derange- 
ment of the system. 

In these orders we have been able to arrange a majority of 
the cutaneous diseases, which thus grouped present strong 
analogies with eaeh other, especially in form. We have 
thought it proper to make some changes in the arrangement 
of species. Thus pemphigus and pompholix appear to us 
to constitute one and the same disease. Jicne is evidently 
not a tubercular disease, hence we have arranged it with the 
pustules, this being its true nature. Erysipelas certainly be- 
longs to the exanthematous, and scabies to the vesicular dis- 
eases, and we have accordingly so placed them. As to the 
diseases that form the seven last orders, they cannot, for the 
most part, be enrolled in any of the sections, as their elemen- 
tary lesions are different, and because they are developed under 
a particular influence, and with symptoms sui generis, hence 
we have preferred to make separate orders of them. 

It should not excite surprise that no mention is here made 
of a multitude of diseases, which are described in a recent 
work, such as anthrax, burns, cyanosis, &c. all foreign to the 
subject In the first place, the plan of this work would not 

3 



j 4 INTRODUCTION. 

admit of it, and besides we were apprehensive of being thought 
to have unnecessarily increased its size in thus accumulating a 
crowd of diseases, which, in fact, are as much misplaced in a 
complete treatise as in a practical abridgment. There is no 
reason why fistulas and wounds which are as much in the pro- 
vince of cutaneous pathology as anthrax, which belongs exclu- 
sively to the subcutaneous cellular tissue, should not be also 

given. . . 

The particular symptoms of the various diseases ot the skin 
may be complicated with each other, and several different pri- 
mary affections are often to be met with on the same indivi- 
dual, particularly in acute eruptions. They are also frequent- 
ly accompanied with general symptoms, and particularly with 
those which indicate some degree of irritation in the mucous 
membranes of the respiratory organs, and still oftener of the 
digestive apparatus. A great number of eruptions follow a 
chronic course, and last months and years without being com- 
plicated with any general disorder or internal derangement 
The cutaneous affections are susceptible of a multitude ot 
modifications, not only in their progress and their colour, but 
also their termination, according to the constitution and age ot 
the patients, the state of health they may be in, and the com- 
bination with internal inflammation. Thus it is very common 
under the influence of an accidental gastro-intestinal irrita- 
tion, to see an eruption, even of a chronic nature, and which 
has lasted for several months, fade, and sometimes gradually 
diminish and wholly disappear, and again appear and slowly 
increase as the patient becomes convalescent. It is a common 
observation in such cases, that "the eruption has struck in 
and has fallen on some important organ," thus taking the ef- 
fect for the cause. Although the internal inflammation evi- 
dently preceded the disappearance of the eruption, the return 
of this latter takes place but slowly, even when the organs 
which had been the seat of the inflammation no longer present 
morbid phenomena. Without here wishing to decide on the 
question of retrocessions, at least in diseases of the skm, it must 
be allowed that these often occur, and if they are not always 



INTRODUCTION. 15 

explainable, or if the disposition of the eruption appears some- 
times to coincide with the development of internal inflamma- 
tion, these cases are rare and prove nothing, for it is well 
known that an organ may be diseased and inflamed for some 
days before it produces any appreciable morbid symptom. 
Why then search for forced explanations, when physiology 
offers those which are natural. Diseases of the skin may de- 
velop themselves under a multitude of different causes, and 
their etiology is not one of the least obscure points of their 
history. 

Some evidently manifest themselves from direct causes, 
which in a majority of cases are appreciable. For instance, the 
influence of stimulating applications, of certain professions and 
conditions of the body, cannot be denied. Thus it it not un- 
common to see a vesicular or vesiculo-pustular eruption after 
blisters, frictions, or irritating lotions; they are also frequently 
seen in those who constantly work among pulverulent sub- 
stances, or who are exposed to a great heat. Several of the 
exanthematous eruptions may arise from irritating substances 
applied to the skin : prurigo may take place from uncleanli- 
ness, &c. &c. 

But, although a certain number of eruptions may occur from 
direct causes, care must be observed not to localise them in a 
general manner, for, on the other hand, it often happens that 
the cutaneous affections are united in a certain degree with 
some derangement of the system, or alteration of some inter- 
nal organ. Thus chronic pemphigus occurs most frequently 
in old age, in the midst of misery and privations; erythema, 
acne, and purpura simplex, often coincide with a plethoric 
state, or derangement of menstruation in woman; roseola, some 
cases of urticaria, &c. accompany febrile attacks; others, as 
pellagra, appear intimately associated with a gastro-intestinal 
irritation. But it is right to observe that if it is true that in- 
flammation of the digestive canal is sometimes met with in dis- 
eases of the skin, the cases where these are only symptomatic 
phenomena of the former, are extremely rare, and that most 



j ( ; INTRODUCTION. 

generally these two classes of disease are rather combined 
than dependant on each other. This is so far true that on the 
one part, the digestive organs are generally in a healthy stole 
in persons affected with diseases of the skin, and it is to that 
point, in the majority of cases, that our remedies are directed, 
and on the other, an inflammation of mucous membrane of the 
intestines often causes the disappearance of a disease ot the 
skin, and that this will again occur on the cure of the internal 
inflammation. . 

But if, as we have observed, the cutaneous inflammations, 
in the greater number of cases, are caused by direct, or at 
least appreciable influences, it is also evident that they appear 
without our being able to assign any cause for their develop- 
ment, that they are sometimes evidently hereditary, that there 
are individuals in whom they frequently return, either at 
fixed periods, as the change of seasons, or on the least devia- 
tion of regimen, from excess, or some mental emotion In 
these cases, which are especially remarkable for a multitude 
of chronic inflammations, lepra, ( dartre furfuracee arron- 
diej and the scaly eruptions generally, lichen, and some pus- 
tular affections, &c. it is impossible not to recognise a hidden 
cause, a particular principle, which is transmissible to a cer- 
tain degree, and whose hereditary succession is undeniable. 

Finally, there are eruptions essentially contagious, as some 
species of porrigo, scabies, §-c. There are some which not 
only may be transmitted by contagion, but carry with them 
a peculiar stamp, and are developed under a special influence 
which is always identical, as variola and syphilis. Others de- 
pend on climate, as elephantiasis Grxcorum, framboesia, 
■molluscum, Src. As to the special cause, that which mflences 
the different forms, by virtue of which, when any excitant is 
given, a cutaneous inflammation is developed in the shape of 
a vesicle and not a papula, and presents itself in round spots 
depressed at the centre, which, under the appearance of small 
scaly disks, somewhat resemble drops of water sprinkled on 
the skin; it is needless to add, is entirely unknown; without 



INTRODUCTION. 



17 



doubt, some day the intimate structure and functions of the 
dermoid system will be better known, and then, and only 
then, these phenomena will be explained. 

The particular diagnosis of diseases of the skin, is that part 
of their study which demands the most care; it is connected 
with all other parts of their history, and without it no opinion 
can be formed, as to the treatment. It is because it is gene- 
rally wanting in almost all writers who have treated of these 
affections; it is because a multitude of eruptions are usually 
mingled in a confused mass, by designating them all under the 
vulgar name of tetter, without attaching any importance to their 
individuality; that we see a physician causing inquietude and 
trouble in a family, by declaring that such an eruption is itch, 
when it is lichen, or prurigo, or eczema; another in declaring 
that a disease is venereal, and exasperating it by giving mercurial 
preparations, when there is no trace of syphilis; this one per- 
mitting a venereal complaint which he had mistaken, to con- 
tinue its ravages; that one again, using incisions and cauteri- 
zations for some simple affection he had taken for a formida- 
ble disease, and which would have yielded to mild applica- 
tions. 

It is therefore of the highest importance to pay strict atten- 
tion to the diagnosis. Moreover, in this resides the whole 
study of cutaneous affections. Let us see in what way this 
can be accomplished, and lay down some general rules, at least 
for the majority of cases. 

The most important point is to ascertain the primary ele- 
mentary lesion, if it has not been destroyed or hidden to a 
certain degree by secondary alterations. This once attained, 
it only remains to compare the disease thus discovered with 
the small number of those which like it have the same con- 
stituents. 

If we suppose the elementary disease to be in a normal state, 
and not to have undergone any alteration, it only is requisite 
to decide if it is constituted of vesicles, pustules, or scales, 
&c. and for this purpose a slight inspection is all that may be 
necessary. When this is accomplished, it must still be dc- 



IS INTRODUCTION. 

cided to what species it belongs; and to do this, recourse must 
be had to some important secondary characters, which form 
such or such genus or variety from their seat, course, &c. 

Thus for example, if a patient presents himself with the in- 
ternal part of the arms, the interval between the fingers, and 
the abdomen, exhibiting small distinct serous spots, pointed 
and transparent at top, accompanied with itching, &c. in 
examining with attention, proof will be had that these do not 
contain pus, that the elevations are not solid and resisting, or 
have a circumscribed induration, still less a papular elevation 
covered with a dry and hard scale; nor an injection disappear- 
ing under pressure; that is to say, it is neither a pustule, a pa- 
pula, a tubercle, a squamous disk, nor an exanthematous 
patch, but in fact a vesicle. Now it only remains to decide 
to which of the vesicular affections this appearance belongs, 
and in proceeding in this way of rejection, a positive diagno- 
sis will soon be arrived at. It is neither miliaria or vari- 
cella, for these two diseases are accompanied with general 
symptoms, and besides, in one the vesicles are numerous and 
globular; in the other, they are larger and more inflamed: it 
is not herpes, for that is characterized by a collection of ve- 
sicles in groups, and here they are scattered. There only re- 
mains eczema and scabies, the vesicles of eczema are flat, 
here they are acuminated; they are generally collected to- 
gether in a greater or less number in eczema, here they are 
distinct, hence it is scabies. 

We have chosen a very simple example, but sometimes the 
diagnosis is more difficult, without the primary disease being 
changed by consecutive alterations ; and scabies itself, which 
is usually recognised with ease, may, under certain circum- 
stances, present much obscurity, especially when it has been 
changed by scratching, but even then a variety of characters 
will serve to point out the true nature of the disease. These 
principally consist in the situation of the eruption, in the ap- 
pearance of its accidental forms, in its precursory symptoms, 
in those which accompany it, &c. 

Jt is not sufficient to merely acquire a knowledge oi the 



INTRODUCTION, 1 § 

primary character, for this often disappears, and the eruption 
presents itself with the consecutive symptoms, a familiar ac- 
quaintance with the secondary modifications of the eruption 
must therefore be possessed. Thus, the fluid contained in a vesi- 
cle may thicken and form a small crust ; a pustule does not re- 
main always in a pustular state, for the fluid concretes, and 
forms a crust of various thickness, this may be succeeded by 
an ulceration ; it is therefore important to be aware of the pe- 
culiar characters of these secondary affections, and above all, 
to what primary disease they belong. Scales, (and here we 
mean those which are soft and yellowish, and the result of an 
effused and thickened fluid, and not the laminae of altered epi- 
dermis,) may succeed vesicles, pustular vesicles, and papulae ; 
crusts are met with after most of the pustular diseases, parti- 
cularly ecthyma, impetigo, porrigo; they also succeed pem- 
phigus, rupia, fyc. Ulcerations may be occasioned by ru- 
pia, ecthyma, fyc. 

Hence, to arrive at a diagnosis, we must first decide on the 
nature of the secondary affection, then ascertain to what pri- 
mary disease it belongs, and afterwards follow the same plan 
as was pointed out above. Thus, a patient presents himself 
with an eruption characterized by yellowish, rough, thick 
crusts, occupying large surfaces on the limbs, and especially 
the legs, which, on their disengagement, leave slight excoria- 
tions, whence flows a purulent fluid, which in concreting forms 
new crusts; the first object of attention are these crusts, the 
least inspection will serve to distinguish them, not only from 
a primary disease, but also from secondary alterations; but it 
is less easy to recognise to what eruption they belong, to ar- 
rive at this, we must recollect what diseases are susceptible of 
presenting these secondary forms. We have seen that crusts 
belonged to some bullar affections, but particularly to the pus- 
tular ; here there is no question of either pemphigus or rupia, 
which are seldom, like this eruption, irregularly dispersed, 
and which manifest themselves in most cases by incrustations 
of a round form, are distinct, and of a black colour, &c. We 
must look exclusively among the pustules, it is neither vari- 



OQ INTRODUCTION. 

ola nor vaccinia, they are characterized by marks too strik- 
ing to be mistaken; it is not ecthyma, for it generally presents 
some large isolated pustules, which become covered with black 
adherent incrustations, leaving ulcerated surfaces on their fall- 
ing off; it is neither acne nor mentagra, for the pustules in 
these two diseases rarely change into real crusts, but usually 
give rise to chronic indurations. There now remains but por- 
rigo and impetigo, and on comparing it with them, we find 
that the first presents distinct characters, which it is needless 
to enumerate in this place, it is sufficient to have indicated in 
what manner the disease could be recognised as impetigo, 
(dartre crust ac'ee flavescent e— Alibert,) and by a little more 
observation, it will be seen that the crusts are scattered with- 
out order over large surfaces, thus indicating the variety, im- 
petigo sparsa. 

Sometimes the characters are not so well marked, and the 
diagnostic offers great difficulties, but We have supposed that 
no distinct primary marks of disease remained, whilst on the 
contrary, in the generality of cases, some are always to be met 
with in a perfect state in the vicinity of the eruption. 

Under some circumstances there exists a union of different 
affections, but the predominant form of the inflammation may 
always be recognised, of which the others are merely ac- 
cidental complications. 

But there are other cases in which it is impossible at first 
to ascertain the true nature of the eruption, such as certain 
chronic inflammations, which, according to the time of their 
duration, lose their primary appearance, and seem to be con- 
founded with diseases of a wholly different order; in such a 
state of things it is only a fresh attack with a reproduction of 
the original symptoms that will enable us to ascertain the true 
nature of the inflammation; sometimes also as they approach 
to a cure they lose these accidental forms, and again resume 
their original characters. 

These general views are only applicable to the first eight 
orders of our table. The others present themselves with par- 
ticular symptoms that cannot be confounded, or rather they 



INTRODUCTION. 21 

may assume the primitive forms of other eruptions, but then 
they also have a special stamp, which, in most cases, leaves no 
doubt as to their nature. 

Finally, it must not be forgotten, that in the diagnosis of 
diseases of the skin, nothing must be overlooked; independ- 
ently of the positive disease, there are a crowd of phenomena, 
such as the seat of the eruption, its form, colour, progress, 
and general state of the patient, which form a certain whole, 
that strikes a practised observer even before he has had time 
to recur to details. 

We have devoted some space to these generalities, because 
we think that these rules may be of great utility, especially as 
they comprise in a great measure those which should be fol- 
lowed in the study of diseases of the skin. 

Well convinced of the importance of diagnosis, we have en- 
deavoured, in the particular descriptions, to give as many de- 
tails as possible. 

The treatment of diseases of the skin experienced the ef- 
fects of the confusion which reigned among them; a single 
curative treatment was applied to them all, and they were for 
a long time, and even are still, attacked, under all circum- 
stances, and in all forms, by the same vulgar means which 
have been considered as specifics, the bitter and sulphurous re- 
medies. 

But, in the last few years, the science has been enriched by 
a mass of precious materials, though they remained for a long 
time useless, for the want of exact knowledge and positive ex- 
perience of their effects, and the circumstances in which they 
were applicable. M. Biett has rendered a most important 
service in filling this hiatus, by his numerous researches and 
precise results. He is perhaps the only one in France who has 
made experiments on all the means that can be used in the 
cure of these diseases, and from which he has derived useful 
results. It is therefore a little extraordinary that some of these 
should have been published, without the author giving him- 
self the trouble to indicate the source from whence he deriv- 
ed his information. 

4 



22 INTRODUCTION. 

In taking a view of the treatment of cutaneous diseases in a 
general manner, we shall pass over that of the acute inflam- 
mations, (rubeola, variola, &c.) which in most cases only re- 
quire an antiphlogistic treatment, and means suited to the in- 
ternal alterations which may complicate them, to occupy our- 
selves with those, which being generally of a chronic charac- 
ter, (although they do sometimes assume a certain acuteness,) 
are very obstinate. 

It is idle to suppose that these diseases generally require 
the sameplan of treatment. It is as certain that some formsyield 
more readily to peculiar modes, as that certain remedies are 
appropriate to particular diseases. This has hitherto been over- 
looked, and we have endeavoured to give it much attention at 
the end of each particular description. 

The treatment of diseases of the skin is general or local, or 
rather it is composed of internal remedies and direct applica- 
tions. It is erroneous in most cases, to rely on one of these 
alone, particularly the latter; for it is evident that a multitude 
of eruptions disappear under the influence of medicines given 
internally, whilst, if a few diseases, purely local, be except- 
ed, such as scabies, they will resist external remedies alone. 
And the theory that has lately been reproduced, which con- 
sists in advising local remedies only, in diseases of the skin, 
is founded on conjectures which betray great want of experi- 
ence, rather than on facts. 

Among the general means, some, as blood-letting, may be 
considered as accessories, although they are very useful in ple- 
thoric and stout individuals, where it is advantageous to make 
one or many detractions of blood, before commencing a treat- 
ment, either to relieve an exacerbation by venesection or 
leeches applied near the eruption, or to oppose the develop- 
ment of an accidental inflammation. 

Others, (purgatives for instance,) are very useful in per- 
sons whose digestive organs are in a normal state, by induc- 
ing a slow and long-continued revulsion; hence it is neces- 
sary in a plurality of cases to employ small doses and to inter- 
mit their use from time to time. 



INTRODUCTION. 23 

Some preparations appear to act powerfully on particular 
symptoms; such are the acids and alkalies which are of so 
great assistance in allaying itching. Some others seem to pos- 
sess special properties, as that crowd of remedies, including 
some bitters, certain sudorifics, and some of the antimonial 
and sulphurous preparations, &c. 

There is also another order of remedies, very energetic it 
is true, which evidently exert a direct action on the dermoid 
system, these are the tincture of cantharides and the arsenical 
preparations. Although they are valuable means in the treat- 
ment of cutaneous affections, although they have effected the 
cure of severe and obstinate diseases which had resisted all 
other remedies for years, and caused both patient and physician 
to despair, they have been the object of violent attacks, they 
have been accused of secretly altering the constitution, and 
inducing deep-seated disease which manifested itself after a 
certain time with fatal symptoms. These reproaches, al- 
though they have been recently repeated in a work where they 
would not be found if it was based on practical researches, are 
wholly destitute of foundation. These preparations, like all 
heroic remedies, are capable of producing accidents if they 
are imprudently administered in immoderate and repeated 
doses; but the same may be said of a multitude of remedies 
introduced for a long time into the materia medica ; mercury, 
sulphate of quinine, and tartar emetic for example. We who 
have seen them employed a great number of times, and who 
might have collected more than one hundred analogous facts, 
can affirm that the results are as follows. 1st. In the greater 
number of cases a complete cure of the most obstinate and in- 
veterate diseases. 2d. Sometimes slight symptoms, arising 
from a gastro-intestinal irritation, which disappear at the end 
of a few days, and permit a recurrence to their use. 3d. Never 
those fatal symptoms that have been proclaimed, by a coward- 
ice that is the more culpable, as it tends to deprive medicine 
of precious remedies, without their rejection being the result 
of any positive fact. We will also add that we have several 
times seen the same patients re-admitted into the Hospital St. 



24 INTRODUCTION 

Louis, months, or even a year after thou' cure, without pre- 
senting any symptom of derangement of their constitute from 

these remedies. . 

The local treatment sometimes consists in determining 
greater degree of excitement in the diseased part , to , has en 
resolution, and among the numerous ointments that have 
been employed for this purpose, those which succeed the best 
are a union of iodine with mercury or sulphur. 

At other times it is useful to modify or change the condi- 
tion of the skin, and in such cases, blisters applied according 
to the plan of Ambrose Parfe, on the diseased surfaces hem 
elves, are a powerful remedy, excitories, on the contrary, 
mp yed as revulsants, are at best useless and often hurtfu h 
I P t sometimes becomes necessary either to entirely change 
the state of the diseased surface, or to limit the ravages of a 
disease which is rapidly extending, and recourse murtbe had to 
caustics, among which we would cite in the first ran* , ^thear 
senical paste of Frere Come, which, if only apphed on small 
po* never occasions accidents; it is an excellent remedy 
as is the acid nitrate of mercury, whose effects are often prompt 

a "imo P n P g y the local means there are few that are so constantly 
useful, and followed by results as advantageous, as the use ot 
baths, and we cannot finish these observations without call mg 
attention to the Hospital of St. Louis, which is one of the 
finest establishments, one of the most complete of its kind, 
and where they administered, with an order and precision 
that is remarkable, to the amount of one hundred and fifty 
thousand yearly. . 

It is to the labours of M. Biett that it owes all the improve- 
ments it presents, and without speaking of the medicated li- 
quid baths of all kinds, or of the dry or other varieties of fu- 
migations administered by the ingenious apparatus of Uarcet, 
of those local fumigations exercised on the diseased parts 
alone, by a plan invented by M. Biett, how much benefit has not 
been rendered by the douches and baths of vapour to crowds 
of "patients. 



DISEASES OF THE SKTN 



ORDER I. 

EXANTHEMATOUS DISEASES. 
EXANTHEMATA. 

BY the term Exanthemata is meant those acute inflamma- 
tions of the skin, which are characterized by a greater or 
less degree of redness, disappearing momentarily under the 
pressure of the finger, and accompanied in most cases with 
general symptoms. Such are the characteristics of erythema, 
erysipelas, roseola, rubeola, scarlatina, and urticaria. 

Symptoms. — All parts of the surface of the skin may be 
affected; some of the exanthematous diseases attack the whole 
superficies of the body at the same moment, whilst others are 
confined to a spot of greater or less extent. Their special seat 
appears to be in the most superficial layers of the dermoid tis- 
sue, although in some cases the whole thickness of this mem- 
brane participates in the inflammation. 

The progress of exanthematous diseases is always acute and 
continued, with the exception, however, of some cases of in- 
termitting urticaria and erythema. Urticaria alone some- 
times continues for months or even years. 

The usual premonitory symptoms are, irregular chills, las- 
situde, a greater or less degree of fever, thirst, and loss of ap- 
petite. But each of these affections possess symptoms pecu- 
liar to themselves. Thus the redness is sometimes diffuse, 
sometimes circumscribed, and the spots, although in general ir- 
regular, assume in certain cases distinct forms. Heat, redness, 
tumefaction, and swelling, accompany erysipelas. Urticaria 



26 EXANTHEMATOUS DISEASES. 

is distinguished by its violent itching. Finally, exanthemous 
disorders are in general accompanied with symptoms of inflam- 
mation of the internal organs, and particularly of the brain and 
pulmonary and gastro-intestinal mucous membranes. 

The usual termination of these affections is by resolution 
and desquamation, although they sometimes end in retro- 
cession or even death; suppuration and gangrene may also be 
induced by erysipelas. 

Appearances on dissection.— -The examination of the bo- 
dies of those who have fallen victims to exanthematous in- 
flammations seldom presents satisfactory results; the usual ap- 
pearances met with, are different degrees of sanguineous con- 
gestion in the various organs, but in some cases evident marks 
of inflammation may be perceived. 

Causes.— Rubeola and scarlatina are induced by a conta- 
gious principle, of which the true nature is entirely unknown, 
and which, with the exception of some rare cases, exercises 
its influence but once on the same individual. The cause of 
the other exanthematous affections may be direct, but they 
depend in general on a particular predisposition of the system 
extremely difficult to understand. Without attempting to pre- 
judge their reciprocal influence, it is evident that they often 
coincide with inflammations of the internal organs. 

Diag?iostic.—The distinctive character assigned to the ex- 
anthemata will distinguish these inflammations from every 
other cutaneous affection; this character alone will always dis- 
tinguish them from purpura and ecchymosis, in which the 
pressure of the finger never causes the disappearance of the mor- 
bid colour of the skin. This red tint which characterizes exan- 
thematous disorders does not take place in the negro, in whom, 
under such circumstances, the black hue is always deepened. 
The exanthematous affections may be complicated with dif- 
ferent papular, vesicular, &c. eruptions, and it was the fre- 
quency of one of these complications in erysipelas that induc- 
ed Willan to class this eruption among the bulla?. 

Prognosis.— The prognosis of these phlegmasia? varies ac- 
cording to their seat or extent, to the age and constitution of 



ERYTHEMA. 27 

the patient, and above all, according to the violence of the 
concomitant inflammations. 

Treatment. — The treatment of exanthematous diseases 
should be antiphlogistic; regimen, diluents, and a moderate 
temperature suffice in most cases. If the symptoms are very 
violent, and important organs are menaced with inflammation, 
there should be no hesitation in resorting to blood-letting, 
either general or local, always graduating it to the state of the 
patient or the particular nature of the exanthematous affection. 

The convalescence in some of these diseases is oftentimes 
very long, and may be retarded by many disorders, among 
which may be particularly cited, whooping cough, anasarca, 
chronic diarrhoea, &c; hence prophylactic treatment should 
be continued for some time after the disappearance of the 
eruption. 

ERYTHEMA. 

The different species of erythema admitted by Willan are 
all designated by Alibert under the denomination of dartre 
erythemoide. 

Erythema is characterized by a slight, superficial, irregu- 
larly circumscribed redness, of various forms and extent. 

It may occur in all parts of the body, but its general seat is 
the face, breast, or limbs, usually confined to one of these re- 
gions, it may extend to several, or even in some cases affect 
nearly the whole superficies of the body. 

Erythema assumes in most cases an acute form, and its du- 
ration varies from one to two weeks. In some rare instances 
it is intermitting, as when it accompanies a fever of that type, 
or when it appears in the paroxysms of a violent fever; in such 
cases its duration is generally dependent on the diseases with 
which it is complicated. 

Symptoms. — Without being usually preceded by any ge- 
neral symptoms, erythema manifests itself by spots of differ- 
ent sizes, of which the redness being vivid and superficial, is 



28 EXANTHEMATOUS DISEASES. 

wholly distinct from the dark and deeper seated colour of 
erysipelas. This redness disappears by pressure with the 
finger, but immediately returns. The form of the spots is ge- 
nerally irregular, but they sometimes assume a definite shape. 
The heat and pain in most cases slight, are in many instances 
scarcely perceptible. Finally, these spots, almost always un- 
accompanied by tumefaction, are sometimes attended with a 
swelling of either an indolent or painful character, which 
gives the eruption a peculiar aspect, and constitutes two mark- 
ed varieties. 

One of these, (E. papulatum, Willan,) most commonly 
attacks females and young persons: it is usually observed on 
the neck, breast, arms, posterior part of the forearm, and es- 
pecially on the back of the hand. The patches are small and 
irregularly rounded, rarely exceeding the size of a centime, 
they are slightly elevated and apparently papular. Red at first, 
they soon assume a violet tint, particularly in the centre. In 
about thirty-six to forty-eight hours the swelling subsides, 
leaving only the red colour which is now on a level with the 
surrounding skin, and disappears in one or two weeks. In 
other cases, on the contrary, the swelling remains and the spots 
appear more elevated, (E. tuberculatum, Will.) 

Another variety, (E. nodosum, Will.) is often met with, 
occurring in infants, women, and young persons of a weak 
constitution and lymphatic temperament. It may appear in 
various parts of the body, but usually it attacks the chm, arms, 
and anterior parts of the legs. In the plurality of cases, a 
state of general uneasiness, depression, and slight fever either 
precedes some days or accompanies the appearance of the 
eruption. This takes place in the form of red, oval spots, a little 
elevated towards the centre, and from a few lines to near one 
inch in diameter. In passing the hand over these spots they 
are felt to be elevated a little above the surface of the skin, 
and forming nodosities; the swelling augments slowly, and 
some days after their first appearance, small, red, painful 
tumours are perceptible, which appear to have a disposition 



ERYTHEMA. 29 

to suppurate, but they soon diminish in size, and a bluish co- 
lour replaces the original red hue; they soften and disappear 
slowly in about ten or twelve days. 

Causes. — Erythema may be either idiopathic or symptoma- 
tic; the first results from the direct or mediate action of vari- 
ous agents on the skin. Thus it is produced by the repeated 
chafing of two contiguous parts of the body, particularly in 
infants or in fat persons. It occurs below the breasts, in the 
arm-pits, groin, and upper parts of the thighs, (Intertrigo, 
Sauvages. J It also takes place on the buttocks and internal 
parts of the thighs, from a forced march on foot or horse- 
back. 

Erythema may also be produced by the action of the sun or 
cold, the contact of leucorrhoeal, gonorrheal or dysenteric 
discharges, urine and faecal matters. It sometimes occurs on 
the upper lip, induced by the acrid fluid which flows from the 
nose in coryza. 

Erythema is oftentimes symptomatic of a gastro-intestinal 
affection, whether acute or chronic, and is most observable 
during the paroxysms. It is often developed in children dur- 
ing dentition. It manifests itself in plethoric persons, and in 
women at their critical period. It often supervenes on the in- 
gestion of irritating substances, and is sometimes observable 
after the administration of the balsam copaiba. 

Idiopathic erythema usually terminates by resolution in a few 
hours, or at most days. Sometimes there is a slight desquama- 
tion, and in some cases, (intertrigo,) there is a secretion of a 
sero-purulent fluid of a nauseous and disagreeable smell. 

Erythema, symptomatic of acute diseases, generally disap- 
pears without any sensible desquamation on the cessation of 
the paroxysms, (E.fugax,) this is also the case when it accom- 
panies intermittent fever, though in some cases it does not ter- 
minate for seven or eight days, and then with a slight desqua- 
mation. 

Erythema may exist with anasarca of the lower limbs; in 
this instance the surface is smooth and shining, with here and 
there confluent patches. ( E. Iseve.) 

5 



30 EXANTHEMATOUS DISEASES. 

It precedes and accompanies a variety of eruptions, and in 
such cases, belongs to their peculiar characteristics. 

Diagnosis. — Not only the other exanthemata, but also 
eruptions of a different class may be confounded with ery- 
thema. Of all these affections, those which present the great- 
est difficulty in their diagnosis, are — 

Erysipelas. — Erythema, which many authors have consi- 
dered as a species or stage of this disease, differs from it how- 
ever in many respects. It can never be mistaken for it, ex- 
cept in those cases where it occupies large surfaces, for the 
circumscribed spots in the other varieties of erythema do not 
permit the least doubt of its nature. In the first case, the red- 
ness is always superficial, the absence of tumefaction, and of 
pain, which is constant, burning, and severe, in erysipelas, the 
mild nature of the complaint, and the rapid and always fa- 
vourable termination of it, are characters which distinguish it 
perfectly. * 

Roseola. — In roseola, the redness is superficial as in ery- 
thema, but it differs from it by being of a characteristic rose 
colour of different tints. The erythema nodosum, which may 
be confounded with the irregular circular spots of roseola, dif- 
fers from it by the redness never being as circumscribed, and 
by the swelling which accompanies it. 

Rubeola and Scarlatina. — These eruptions differ from 
erythema, the one by the irregular semi-lunar form of its 
spots, and the other by the raspberry colour of the large 
patches which characterize it, added to which these two dis- 
eases are contagious, and are accompanied by a train of pecu- 
liar symptoms. 

Urticaria. — Erythema papulatum is the only variety that 
can be mistaken for urticaria, but this latter disease differs 

* Mr. Lawrence in an able paper on Erysipelas, in the fourteenth volume 
of the Medico-Chirurgical Transactions, classes erythema as the first and 
most simple form of that disease. Cullen places it among the phlegmasia. 
J. P. Franck includes under this head gutta rosea, chilblain, and ranks it 
among the impetigenes. Joseph Franck has added nxvi materni to the list. 
—Trans. 



ERYTHEMA. 31 

from it by the greater elevation of its spots, by the absence of 
the violet colour observable in erythema, by the itching which 
accompanies it, and by its irregular and oftentimes rapid 
course. 

Lichen urticatus. — The above variety of erythema may be 
confounded with lichen urticatus, but in the latter, the pa- 
pulae are smaller, rounder, and more solid, their colour is not 
so deep, and, as in urticaria, there is always great itching. 

Syphilitic spots. — These spots might, at the first glance, 
offer some resemblance to erythema, but their duration, and 
their coppery or grayish hue will always suffice to distinguish 
them, besides they are usually accompanied by other venereal 
symptoms. 

Prognosis. — Erythema is never fatal. 

Treatment. — Idiopathic erythema rapidly disappears with 
the cessation of the causes which developed it: soothing lo- 
tions, warm baths, and attention to cleanliness, are all that are 
necessary. When it arises from the attrition of surfaces, either 
in infants, or in corpulent persons, it must be sprinkled with 
an absorbent powder, as that of the lycopodium, and the chaf- 
ing prevented as much as possible.* 

The treatment of symptomatic erythema depends on the dis- 
ease which it accompanies; in curing a gastro-enteritis, of 
which it may be one of the symptoms, it also disappears. 

Those erythemas, or morbid rednesses which often occur in 
women at their critical period, or which coincide with a de- 
lay or suppression of the menstrual discharge, demand blood- 
letting, diluents, regimen, and other means of reduction. 

The erythema nodosum does not require any particular 
treatment, although it is the worst form of the disease ; topical 
applications are useless: baths and light laxatives, and in some 
rare cases, small blood-lettings, constitute all the treatment. 

* This variety of erythema is very troublesome during the summer in cor- 
pulent persons, and requires frequent ablutions with tepid water to remove 
the viscous secretion. Hair powder forms an excellent application after the 
eruption has been washed.— Trans. 



32 EXANTHEMATOUS DISEASES 



Erysipelas. 

Erysipelas is an exanthematous affection which is not conta- 
gious, characterized by a deep red colour of the skin, accom- 
panied with heat and swelling, which often extends to the sub- 
cutaneous cellular tissue, occupying a greater or less extent of 
surface, and capable in some rare cases of becoming general. 

Although it attacks all parts of the body, the face and limbs 
are the most usual seats of the disease. 

Symptoms.— In erysipelas the inflammation of the skin 
may be confined to this membrane, sometimes accompanied by 
an irritation of the subcutaneous cellular tissue, or this tissue 
may be inflamed in various degrees, giving rise to severe symp- 
toms. From these circumstances we shall divide erysipelas 
into two varieties: erysipelas and phlegmonous erysipelas. Both 
these varieties may occur simultaneously in a great number 
of cases, but as there exists a marked difference between them, 
both in their progress and the treatment they require, a suc- 
cint description of each appears necessary.* 

The precursory symptoms, as lassitude, general depression, 
transient but at times very severe chills, hardness and frequen- 
cy of the pulse, nausea, pain in the epigastrium, thirst, ano- 
rexia, and constipation, are common to both varieties. About 
the second or third day of the febrile attack the eruption makes 
its appearance, although in some instances it is developed much 

sooner. 

1st. True erysipelas, or that in which the inflammation 
does not extend beyond the skin, presents itself with the fol- 
lowing characters; a deep red colour occupying a greater or 
less extent of the skin, which shows by the elevation of its 
edges that this inflamed part is tumefied; this redness disap- 
pears momentarily from pressure with the finger, which pressure 
is in general very painful, there exists a greater or less degree 
of pain accompanied with a tingling and burning sensation, the 

* Mr. Lawrence divides erysipelas into three varieties: E. simplex, E. cede- 
matodes, and E. phlegmonosum.— Trans. 



ERYSIPELAS. 33 

pulse is accelerated, there is nausea and thirst, the mouth is 
bitter, and the tongue covered with a white coat. The cuticle 
which covers the inflamed part is sometimes raised to a greater 
or less extent by a yellowish serum, and these vesications may 
acquire a considerable size. They usually appear about the 
third or fourth day, and sometimes break on the day succeed- 
ing their appearance, at other times later, and discharge a vis- 
cous fluid, which in many cases forms small scabs. 

The general symptoms ordinarily follow the progress of the 
eruption, augmenting or declining with it, in some instances, 
however, they are very slight notwithstanding the extent of 
the erysipelas, and vice versa. 

Towards the fifth or sixth day, the redness diminishes and 
assumes a yellowish tinge, the swelling is less, and the cuticle 
is covered with a multitude of small wrinkles; by degrees the 
morbid discoloration disappears, and desquamation takes place 
in the affected parts. This is the most frequent and favoura- 
ble termination of the disease, but where vesications have ex- 
isted, the skin is covered with small brown scabs, which remain 
for some length of time. 

Instead of passing through its various stages where it was 
first developed, erysipelas may successively attack different 
parts of the body, and disappear from that which was first af- 
fected. % At other times it gradually extends over a greater 
surface without disappearing from its original point of attack, 
so as, in some rare instances, to cover the whole body at the 
same moment. In certain cases it suddenly disappears and at- 
tacks another spot, leaving no other traces than a slight des- 
quamation. (E. erraticum.J 

In individuals of a lax and lymphatic constitution, erysipe- 
las may be accompanied with oedema, particularly where it at- 
tacks the lower extremities. In this case the redness is lighter 
and in some instances scarcely perceptible, the skin is smooth 
and polished, and retains for some time the impression of the 

* A metastasis of erysipelas may sometimes take place to the heart or head. 
Mr. Adams gives some interesting' instances of these in the Dublin Hospital 
Reports, Vol. IV.— Trans. 



34 EXANTHEMATOUS DISEASES. 

finger. The termination of erysipelas when thus accompani- 
ed with oedema is favourable, and should not cause disquietude, 
but this is not the case when the eruption follows oedema, as is 
sometimes observed in anasarcous patients, and above all when 
it arises from scarifications which have been made to draw off 
the water, for in these cases gangrene is apt to ensue; this is 
announced by the inflamed skin assuming a livid hue, the blis- 
tered epidermis forms large irregular phlyctenae filled with a 
brownish fluid, and in persons already exhausted by disease, 
death rapidly ensues. The genital organs and lower extre- 
mities are particularly obnoxious to this consecutive erysipelas. 
(E. cedematodes, Willan. ) 

2d. Phlegmonous erysipelasis accompanied with an inflam- 
mation of the cellular tissue, and may attack all parts of the 
body, but is generally observed on the extremities, being some- 
times confined to one spot, and at others extending over the 
whole limb. 

In this variety, the symptoms are always more violent than 
in true erysipelas, but they differ according to the extent and 
depth of the inflammation, and the anatomical structure of the 
affected parts. 

When the cellular tissue is not very deeply inflamed, the 
eruption is accompanied with a violent burning pain, conside- 
rable swelling, and high fever. Pressure on the part is very 
painful, and the skin regains its morbid colour but slowly. 

Termination by resolution may take place towards the fifth 
or sixth day, but in general the pain becomes throbbing, the 
redness diminishes, and abscesses are formed which discharge 
laudable pus, sometimes mixed with small shreds of dead cel- 
lular membrane. When the cellular tissue is more deeply af- 
fected, or when the phlegmonous erysipelas attacks the whole 
of a limb, the disease is oftentimes rapid in its progress, and the 
cellular tissue appears inflamed at the same time as the skin, 
and in some instances even before. When this is the case, 
the pain is extreme, the least movement of the limb causing 
the patient to cry out, the skin is red, much distended and ex- 
ceedingly painful on the least pressure ; the pulse is frequent, 



ERYSIPELAS. 35 

hard, and corded; there is often delirium, violent thirst, dry- 
ness of the tongue, and profuse sweats. The termination, ex- 
cept from an energetic treatment, is seldom by resolution; the 
suppuration, which takes place from the fifth to the seventh 
day, though sometimes sooner, is accompanied with uncertain 
chills, the redness of the skin and pain diminish, but the swell- 
ing increases, there is much doughiness, and the limb remains 
in that state for some time; in some cases the pus remains for 
a long time before an opening is formed in the skin to give it 
vent, but in general it escapes either by a natural or an artificial 
orifice, mingled with shreds of gangrenous cellular tissue. In 
these cases the course of the disease is ordinarily tedious, si- 
nuses are formed, sometimes sloughing of the skin takes place 
to a considerable extent, and colliquative diarrhoea often car- 
ries off the patient, exhausted by the slow fever and great sup- 
puration. 

The symptoms of phlegmonous erysipelas may be still more 
severe, particularly when the aponeuroses, in opposing the 
swelling, produce strangulations, as is observable in the hands 
and feet. In these cases the general symptoms are very violent, 
violet spots appear on the inflamed surface about the second 
or third day, the skin loses its sensibility, these spots increase 
rapidly and are covered with vesications, eschars are formed, 
which, however, are small when a proper treatment is pursued, 
these gradually fall off, and convalescence takes place after a 
greater or less degree of suppuration. But when the disease 
occupies a great extent, and this order of things occurs, the 
system soon becomes implicated, symptoms of severe gastro- 
intestinal irritation supervene, characterized by prostration of 
strength, dryness of the tongue, much diarrhoea, great frequen- 
cy of the pulse, &c. to these are sometimes superadded taci- 
turn delirium, flightiness, coma, a great alteration of the fea- 
tures, and death rapidly ensues. 

Erysipelas offers some modifications, according to the spot 
it occupies, which deserve to be noticed. 

Erysipelas of the face is the most frequent form of the 
disease; it generally commences at the nose, one of the cheeks, 



36 EXANTHEMATOUS DISEASES. 

or eyelids, and gradually extends till the whole face is involv- 
ed, the features rapidly become unrecognisable; the swelling 
of the eyelids is often extreme. There are at the same time 
general symptoms of greater or less intensity, such as fre- 
quency of the pulse, heat of skin, violent head-ache, wakeful- 
ness, excitement of mind, and slight delirium during the night. 
These general symptoms are in some cases strong, whilst in 
others they are scarcely perceptible. The eruption generally 
attains its height about the fourth or fifth day, and resolution 
takes place on the eighth. 

Erysipelas of the scalp often succeeds that of the face. At 
other times, it arises from punctures, contusions, operations, 
&c. It is marked by cedematous swelling, and great sensibi- 
lity of the inflamed skin; the redness is slight, being in many 
instances of a light rose tint. Termination by suppuration is 
extremely common in this variety, and the subcutaneous cel- 
lular tissue often becomes gangrenous; but mortification of the 
scalp itself rarely occurs; this arises from the anatomical ar- 
rangement of its vessels, which, as is remarked by Dupuytren, 
are distributed in large numbers over its internal surface. Cere- 
bral symptoms are most to be feared, and are more frequent 
in this variety than in the others. 

Erysipelas of the breasts in women* is generally of the 
phlegmonous character. It often occurs in females recently 
delivered, and in whom the mammse are much developed, with 
peculiar symptoms; there is at first violent pain, but unaccom- 
panied with swelling; the skin only presents a rose colour 
around the nipple, the redness extends itself in an irregular 
form from this spot, and is bounded by small phlyctenae, 
somewhat resembling those in herpes, but as it gradually 
spreads, the skin which was primarily affected, becomes of a 
yellowish-white colour, and loses its sensibility; and at the 
end of two or three days, when the eruption declines, this 
membrane is found to be gangrenous over the whole space 
from the nipple to the point at which the erysipelas had ter- 
minated. This diseased skin does not at first emit any smell, 
but is gradually detached by suppuration, during which pro 



ERYSIPELAS. 37 

cess the odour is very fetid. A large ulcerated surface is form- 
ed, the cicatrization of which is extremely tedious. Both 
breasts may be affected with the disease, but whatever may be 
the extent of the gangrene, the nipples and the areola sur- 
rounding them remain uninjured. 

Erysipelas of the umbilical region is often observed in 
newly-born children in hospitals, and in institutions for found- 
lings. It is attributed to injury done the chord, and above 
all, to the influence of the vitiated atmosphere inhaled by the 
children in these establishments; it sometimes extends to the 
hypogastrium and genitals, which are apt to become gangren- 
ous, and in such case, death is almost inevitable. 

Erysipelas of the limbs is sometimes of little extent, whilst 
at others, the whole member becomes implicated, and in these 
cases it often terminates by suppuration at one spot, whilst re- 
solution takes place elsewhere. 

The most dangerous complications of erysipelas are without 
doubt, those with cerebral and gastro-intestinal inflammation, 
which may occur of very high grades, and speedily destroy 
the patient. In these cases, the eruption generally disappears 
as soon as the disease of the other parts developes itself, though 
they sometimes exist simultaneously. Swelling of the parotid 
glands is a very common attendant on erysipelas of the face. 

The terminations of erysipelas are by resolution, retroces- 
sion, suppuration, gangrene, and death; the first is fortunately 
the most common ; it is often preceded, particularly in erysi- 
pelas of the face, by a profuse bleeding from the nose. 

Dissection. —In cases of severe erysipelas, not only are 
traces of inflammation of the skin discoverable, but the subcu- 
taneous cellular tissue is found very friable and infiltrated with 
pus, which is in many cases collected in particular spots. 

When death has suddenly taken place from a violent cere- 
bral affection, no appreciable pathological lesions are percepti- 
ble. At other times, diseases either of the lungs or alimentary 
canal are met with, whose existence had never been suspected. 
Causes.— Erysipelas may attack all ages, both sexes, and 
at all seasons, but is more generally met with in females, and 

6 



38 EXANTHEMATOUS DISEASES. 

those individuals in whom the skin is fine and delicate; and is 
most common in spring and autumn. 

Certain external causes acting directly or mediately on the 
skin, mav cause its development, as heat, cold, irritating ap- 
plications, punctured and contused wounds, slight surgical 
operations, &c. But even in these cases, it appears to be de- 
pendent on some unknown predisposition of body. 

There are other causes which also exercise a marked influ- 
ence on the appearance of this disease, as the habitual use of 
gross food, putrified meat, high seasonings, fermented liquors, 
excess in food, &c. &c. 

It often appears at the time of the establishment of men- 
struation, at the critical period, and on the suppression of some 
habitual evacuation. Its attack is often induced by strong 
mental excitement, profound grief, or violent fits of anger, 
and sometimes accompanies a gastric disorder, particularly in 
old persons. But it is most generally observable m indivi- 
duals affected with a chronic irritation of the digestive organs, 
in those who have been confined for a length of time in 
prisons, hospitals, or places where the air becomes vitiated. 
Finally, it frequently occurs in the course of acute gastroin- 
testinal affections, or in inflammations of other organs; and it 
it generally augments the danger, still there are cases where 
its appearance is critical and salutary. 

Diagnosis.— The character of the symptoms m erysipelas, 
are too well marked for any difficulty to arise as to its nature. 
A close examination, however, is sometimes necessary to re- 
cognise it when seated in the scalp, particularly when it oc- 
curs with a disease, whose symptoms are the most prominent, 
* Prognosis.Simj>\e erysipelas of little extent is a disease 
unaccompanied with danger, but far different is the case when 
it involves a lar*e surface, or is complicated with inflamma- 
tions of the brain or digestive organs. Erratic erysipelas, 
when it has lasted for some time, indicates a state of the sys- 
tem, from which serious consequences may be apprehended. 

The prognosis of this disease in persons affected with ana- 
sarca is generally fatal; the same remark is applicable when it 



ERYSIPELAS. 39 

attacks individuals who have lived for a long time in prisons, 
hospitals, &c. When erysipelas occurs during a pleurisy, 
pneumonia, gastritis, &c. its danger is dependent in a great 
measure on the general symptoms. 

The sudden and spontaneous disappearance of this eruption, 
preceded or followed by violent symptoms, indicates an in- 
flammation of some of the vital organs, and is always a bad 
omen. 

The prognosis of phlegmonous erysipelas is generally bad, 
and becomes worse if this is of any great extent. 

Finally, much is to be apprehended, when the skin, which 
is the seat of the inflammation, becomes gangrenous, and ady- 
namic symptoms are at the same time developed. 

Treatment. — When erysipelas, whatever may be its cause, 
is simple, of little extent, and does not cause any general dis- 
turbance of the system, it is sufficient that the patient should 
be kept on a low diet, and diluent drinks administered; the 
disease pursues a regular course, and seldom requires any other 
curative means. 

Lotions of Goulard's extract used cold, produce beneficial 
effects in that variety of the disease known under the name of 
cngelure. 

When the eruption is extensive, and there are general 
symptoms, as takes place in most cases of symptomatic erysi- 
pelas, recourse must be had to more active treatment, as blood- 
letting, emetics, purgatives, and certain local applications. 

Blood-letting is generally indispensable in these cases, and 
must be promptly resorted to, where the patients are young 
and plethoric, or where the general reaction is well marked: 
the inflammatory fever which precedes the eruption most im- 
periously demands this remedy, when it is high. Bleeding 
from the arm is preferable to that from the foot, even in cases 
of erysipelas of the face, as the quantity of blood to be drawn 
is more readily obtained; venesection must be repeated seve- 
ral times if the symptoms require it. If, after the reduction 
of the pulse, the eruption is still great, local bleedings are to 
be resorted to, particularly where the inflammation is situated 



40 EXANTHEMATOUS DISEASES. 

on the face or scalp. It is, however, often advantageous to 
use local bleedings simultaneously with general venesection, 
taking care always to practice them at a little distance from 
the seat of the eruption, and never on the inflamed surface 
itself. 

Blood-letting is to be repeated according to the pertinacity 
or increase of the symptoms: there are cases, however, w T here, 
notwithstanding the apparent violence of the disease, great 
precaution must be used in its employment; as when the erup- 
tion appears in patients already enfeebled, either by previous 
disease, or by the energetic treatment requisite for its cure, 
and in persons who have been confined for a length of time in 
prisons, &c* 

Emetics, which were formerly used in an indiscriminate 
manner in the treatment of erysipelas, particularly where 
there was bitterness of the mouth, and a yellowish coat on the 
tongue, should never be used without precaution. In fact, 
these very symptoms occur in diseases where the use of eme- 
tics is dangerous. They should also never be employed where 
there exists dryness of the skin, violent thirst, heat at the epi- 
gastrium, and high fever. 

Purgatives are preferable to emetics in relieving the sabur- 
ral state which often exists with erysipelas of the face; the 
revulsive effect they produce on the intestinal canal is advan- 
tageous. But their use should be guided by the same rules as 
those for emetics. In the majority of cases, laxatives and mild 
purgatives are sufficient. 

Local applications are generally useless in the cure of 
erysipelas; above all refrigerant applications must be avoided, 
as they have often caused fatal effects. Ointments and cata- 
plasms will only augment the inflammation. Vesicatories 

* Local bleeding" by means of leeches has been much deprecated by some 
authors, as Willan and Thomson, but the generality of recent authors agree 
in its utility, for, although leech bites often produce an appearance similar to 
erysipelas, on the sound skin of some individuals, yet they do not occasion 
this effect on this membrane when in an inflamed state. See an interesting 
paper on this subject, by Henry Neill, M. D. in the North American Medical 
and Surgical Journal, Vol. I. p. 295. — Tracts. 



ERYSIPELAS. 4J 

should only be employed to fix the erratic form of the disease 
or to bring back the eruption to the part first attacked, when 
■t has uddenly disappeared, and this disappearance is followed 
by violent symptoms.* 

Phlegmonous erysipelas demands a very energetic treat 
-nt, which must be modified by the extent audience o^ 
the disease General and local bleedings must be used with 
-gour, and at the commencement of the'attack; afterward! e 
course must be had to emollient local baths, continued for a 
ong ttme as well to favour the flow of blood, as to relieve 
the ereth.sm of the diseased part. 

oloTT th Ilt meanS ^ UnSUCcessfu] > ° r have not been em- 
ployed, and the symptoms rapidly increase, we must resort to 

vised "but Z f ^T " e haS tSken P ' aCe ' aS has bee " •*- 
vised, but before, to endeavour to prevent it 

The extent of the incisions must vary according to the state 
of the disease, and its seat. The object in making them st 
relieve the tension of the aponeuroses, and consequently h 
inflammatory strangulation. Incision, are also necessary when 

their use was laid aE » T S "** '" fte *' me ° f Ambrose Pare 
most benefit Zl » I ^2T*« * * »***. the y are 
moderately tense and hot tZ t T ■ """^ a " d ^^ red ' *<= ski » 
genera. rLZTl^VLZ 'l^ "f^ ** ** 

"ys that a wash of tL f , . of P rodu <=»>g: salivation. Dr. Chapman 

lu'ted on Z^llZTVTTI 00 " ^ SUbHmate > " — el 



42 EXANTHEMATOUS DISEASES. 

phlegmonous erysipelas terminates by suppuration, or to pre- 
vent gangrene.* 

Compression has been proposed as very advantageous in 
phlegmonous erysipelas, but in reflecting on the violent symp- 
toms which so often take place in fractures, where, from the 
application of a simple bandage, the limb swells; the use of 
this means appears to us too hazardous to be adopted; besides, 
as it can only be employed at the commencement of the dis- 
ease, and that at this time the advantages of an antiphlogistic 
treatment is incontestable, we must have stronger proofs of its 
efficacy, before we would sacrifice so much precious time.t 

Roseola. — Roseola, Willan. 

Roseola is an exanthematous eruption which is not contagi- 
ous, characterized by rose-red spots of various forms, which 
are not prominent; its appearance is in general preceded and 
accompanied with febrile symptoms. 

The whole surface of the skin may be the seat of the dis- 
ease, although at times it is only developed on parts, as the 
body or limbs. 

Its course is always acute, but varies according to the indi- 
vidual, the cause, or the diseases which it accompanies. 

Its duration varies from twenty-four hours to a week. 

Symptoms. — In very young children, an eruption of nu- 
merous, nearly circular spots, contiguous to each other, and 
of a deep rose-red colour, is oftentimes observable; these spots 

• The propriety of using incisions in erysipelas, has caused many acrimo- 
nious disputes in England. Mr. Lawrence, Mr. Brodie, and others, recom- 
mend them to be extensively used, whilst Mr. Hutchinson prefers small ones; 
but there can be no doubt of the utility of incisions in cases where the ten- 
sion is great, they relieve the pain, and arrest the progress of the disease. 
Mr. Lawrence is of opinion that they are of the greatest advantage at the 
commencement of the attack. — Traxs. 

f Compression in erysipelas was first recommended by Velpeau, and was 
extensively used by himself and Mr. Bretonneau with astonishing success, 
but has not proved equally efficacious in other hands, and, as is observed in 
the text, been followed by serious consequences.— Trass. 



ROSEOLA. 43 

are from four to six lines in diameter, and disappear in the space 
of twenty-four to thirty-six hours. Their appearance is gene- 
rally connected with some gastro-intestinal disorder. 

A similar eruption often occurs during dentition; in such 
case after vomitings, fever, diarrhoea, and sometimes slight 
convulsions; rose-red, irregular, distinct, although nearly con- 
fluent spots, appear on the surface of the body. These disap- 
pear in the space of twenty-four hours, but in some cases they 
recede and return for several days. 

The most severe form of roseola occurs in summer, (R. sestiva, 
Willan. ) It is generally preceded in children by alternations of 
chills and fever, by lassitude, head-ache, sometimes by excite- 
ment, slight delirium, or even convulsions; there is at the same 
time, heat of skin, thirst, loss of appetite, constipation, or diar- 
rhoea; the eruption appears from the third to the seventh day, dat- 
ing from the commencement of these symptoms; it first shows 
itself on the face or neck, from whence it spreads, in the space 
of twenty-four to forty-eight hours, over the whole body; the 
redness of, these spots is deeper, and their form more irregu- 
lar than those of rubeola, and this red colour changes into a 
deep rose tint. The patient at the same time experiences vio- 
lent itching, the fever continues, and deglutition is often pain- 
ful. The progress of this eruption is very irregular. There 
may even be a total absence of all febrile symptoms. Its du- 
ration is from three to four days; it disappears without any 
appreciable desquamation; in some instances it returns again, 
in which case its attack is prolonged. 

An analogous eruption occurs in the autumn, (R. autumna- 
lis, Willan,) and only differs from the preceding by the spots 
being somewhat larger, and their being seated in the upper 
extremities, and in the absence of fever. 

There is a singular variety of this disease, in which all parts 
of the body are covered with rosy spots in the form of rings, 
(R. annulata, Willan,) the centres of which preserve the na- 
tural colour of the skin. These rings, whose diameter is at first 
from one to two lines, gradually enlarge, leaving in their cen- 
tre an uncolourecl spot, which is at one time large and at others 



44 EXANTHEMATOUS DISEASES. 

small; sometimes two, or even three rings surround each other, 
the skin maintaining its natural colour in the intervals between 
them. The duration of this eruption is short when it is ac- 
companied with fever. At other times it may continue for an 
indefinite time, in which case it is generally attended with 
chronic affections of the digestive organs. 

Causes. — Roseola may occur at all ages and in both sexes, 
but is most common in women and children, and takes place 
rather in summer and autumn, than at other seasons. It may 
repeatedly attack the same person. It has been known to 
reign epidemically, and M. Biett has several times observed 
it in this form, in the dispensary of the Hospital of St. Louis, 
during very warm summers. Roseola may precede the erup- 
tion of either natural or inoculated small-pox; in some chil- 
dren it appears on the ninth or tenth day after vaccination ; 
the first dentition, ingestion of cold drinks whilst the body is 
in a state of perspiration, and laborious exercise, are frequent 
causes of this disease, which also is a frequent concomitant of 
gastro-intestinal irritation in children. 

Diagnosis. — Roseola has often been mistaken for rubeola 
or scarlatina, but the spots in this disease are almost invaria- 
bly of a circular form, are circumscribed, of a deep red co- 
lour, and larger than those of rubeola, and smaller than those 
of scarlatina. It is never contagious. In rubeola the spots 
are small, irregularly semilunar, and of a bright red colour; 
those of scarlatina are large and of a raspberry hue. Both 
these diseases are contagious, and their general symptoms are 
well marked; nevertheless the most experienced practitioner 
may mistake them, especially at their commencement. 

The greater extent of the rings and the absence of vesicles, 
distinguishes roseola annulata from herpes iris. 

Prognosis. — The prognosis of roseola is always favoura- 
ble; the occurrence of some disease of the internal organs at 
the same time, alone can render it fatal. 

Treatment. — In all cases a proper regimen, diluent drinks, 
moderate temperature, and rest, are all that are required. 
That form of the disease which occurs in vaccinated persons, 



RUBEOLA. 45 

does not demand any particular treatment. In cases where it 
is complicated with inflammation of some vital organ, the 
treatment must be directed to that. 

Rubeola. 

Rubeola is a contagious affection, accompanied at its com- 
mencement with coryza, serous discharge from the eyes, 
cough, and fever, and appearing in the form of small red spots, 
which are slightly elevated, and at first distinct, but afterwards 
become united, and assume an irregularly semi-lunar shape, 
leaving small intervals of unaltered skin between them. * The 
progress of the disease is always acute; its duration is from 
eight to ten days, but some of the symptoms often remain a 
much longer time. The continuance of the eruption itself is 
from three to four days. 

Symptoms. — The attack of rubeola is marked in the ma- 
jority of cases by a state of general uneasiness, lassitude of the 
limbs, alternations of chills and heat, bleeding from the nose, 
and vomiting. These are soon succeeded by a greater or less 
acceleration of the pulse,heat of skin, sneezing, serous discharge 
from the nostrils and eyes, coryza, frequent and dry cough, 
slight angina, thirst, anorexia, nausea, white and moist tongue, 
constipation, scanty and red urine, head-ache, coma, and some- 
times convulsions in children. 

These symptoms are developed in the first forty -eight hours, 
their violence, as well as that of the fever augments the third 
and fourth day; there is then great heat of skin, general un- 
easiness, sweats, great sensibility of the conjunctiva and eye- 
lids, coryza, hoarseness, fatiguing cough, greater or less de- 



Dr. Chapman is of opinion that this disease is not contagious, as from 
experiments performed in the Philadelphia Dispensary in 1801, in which 
:he blood, the tears, the mucus of the nostrils and bronchia, the eruptive 
matter in the cuticle, were all tried without effect. 

It has been said that the measles appear epidemically every seven years, 
DUt on this point there is as yet no certainty, although there is no doubt of 
ts recurring very nearly at this period. — Trans. 

7 



46 EXANTHEMATOUS DISEASES. 

gree of dyspnoea, redness of the tongue, sometimes vomiting, 
cephalalgia, and in some cases transient delirium. At this 
time the palate and uvula are covered with small red spots, 
which rapidly become confluent. 

Towards the fourth or fifth day, small red spots, which are 
distinct, circular, slightly elevated, and apparently papular, 
appear on the forehead, chin, nose and cheeks, and in a short 
time the neck, breast, body and limbs, are successively co- 
vered with the same eruption. The red spots enlarge and be- 
come somewhat prominent, resembling flea-bites in their form. 
A small vesicle is often observable towards their centre; 
their number soon augments, and in becoming confluent they 
form larger patches, of an irregular, semi-lunar shape, having 
small spaces interposed between them in which the skin pre- 
serves its natural colour. In some cases, particularly on the 
face and hands, a sensation of an unequal surface is experienc- 
ed, in passing the finger over the eruption. 

The redness of the spots usually attains its height in about 
twenty-four hours after their appearance, and the eruption ter- 
minates in about thirty-six hours. The face is often swelled 
at this time, and in some cases the tumefaction of the eyelids 
prevents vision. On the sixth day of the disease, the redness 
diminishes on the body, but augments on other parts. On the 
seventh, the eruption begins to fade, and on the ninth slight 
yellowish spots indicate the spots it occupied. The eruption 
pursues much the same course in its disappearance as in its at- 
tack, and is followed by desquamation, usually attended with 
violent itching. 

Instead of diminishing as the eruption increases, the heat, 
thirst, coryza, and cough rather augments, but the pulse 
becomes less frequent; these symptoms generally cease as the 
eruption fades. The cough remains longer than the other 
symptoms; sometimes bleeding from the nose takes place to- 
wards the close of the disease, and there is often a slight diar- 
rhoea, which appears to hasten the convalescence. 

Such is the most usual course of rubeola, but in some cases 
there is scarcely any eruption, whilst in others it is very ex- 



RUBEOLA. 47 

tensive. In some patients the redness of the spots is very 
great, and in others on the contrary, they are scarcely per- 
ceptible. 

Measles may be complicated with other diseases. It is 
rarely accompanied with petechia?, but, as has been observed 
in many instances, by M. Biett, the spots may assume the 
form and colour of purpura simplex, in which case they do 
not disappear by pressure. Those combinations which merit 
attention are with — 

The cerebral affections; these are often followed by serous 
effusions into the ventricles; with pulmonary inflammation and 
that of the gastro-intestinal mucous membrane. In these cases 
ataxic and adynamic symptoms supervene. 

The complication with croup is very fatal, but fortunately 
it is of rare occurrence. Finally, measles may be accompanied 
with various other eruptions, either vesicular, bullar, or pus- 
tular. 

The convalescence, independent of these combinations 
which retard it, also may give rise to a great number of dif- 
ferent diseases; thus chronic ophthalmia, inflammations of the 
respiratory passages, otitis with deafness, and chronic phleg- 
masiae of the vessels and lymphatic glands, may all take place. 
In persons predisposed to phthisis, the development of tuber- 
cles appears to be hastened by the continuance of the catarrh 
subsequent to the eruption; and also the convalescence from 
this affection may be retarded, as in scarlatina, by acute dropsy, 
a circumstance, which, however, is observed more frequently 
in the latter disease. 

In the generality of cases, measles follows a regular course 
and terminates happily. But in some instances death takes place, 
in which case it should be attributed to one of the complica- 
tions of the disease, for on dissection traces of inflammation 
and congestion are met with ; the brain, lungs, and stomach, 
are the organs which most frequently present these appear- 
ances. 

Causes. — Measles is induced by an unknown morbific prin- 
ciple, which is transmitted bv contact and infection, and in 



4S EXANTHEMATOUS DISEASES. 

general exercises its power but once on an individual. The 
experiments tending to prove that inoculation with blood of 
persons affected with rubeola can cause the disease, are any 
thing but conclusive. 

Measles may occur in all climates, and ordinarily appears as 
an epidemic. In some of these, the morbific cause may only in- 
duce coryza, and symptoms of mucous irritation of the pulmo- 
nary organs in certain individuals, but in some rare cases the 
eruption is unaccompanied by any of these symptoms. Such 
individuals are not protected against a second attack. No age 
is exempt, but it usually affects young persons. It prevails 
more generally during the winter and commencement of the 
spring, than at other seasons. The appearance of this disease 
is from the tenth to the fourteenth day from the infection. 

Diagnosis. — The course of the disease, the nature of the 
symptoms, and the character of the eruption, will always suf- 
fice to distinguish rubeola from scarlatina. In measles, the 
precursory symptoms precede the eruption from three to four 
days, the spots are smaller, of a vivid red colour, and irregularly 
semilunar, having between them intervals of unaltered skin. 
In scarlatina, the eruption is more rapid in its appearance, 
the spots are larger, more irregular and of a raspberry colour. 

As the eruption of scarlatina does not disappear in a uni- 
form manner, but by intervals, towards the end of the fifth day 
small irregular spots may be perceived, that are readily to be 
mistaken for measles. There are also cases in which the diag- 
nosis is really difficult, as where large spots of an uniform red, 
cover different parts of the body, and there are symptoms of 
irritation of the mucous membranes, resembling those in scar- 
latina. In these cases attention must be paid to the reigning 
epidemic, and to the predominant symptoms of the disease; the 
fact of a previous infection should not prevent the physician 
from making an attentive examination, for it is proved that | 
the same person may be twice attacked with measles. 

As to roseola, the deep rose-red colour of its eruption, andl 
circular form of the spots, their size, and its almost uncontagi-l 
ous nature, marks it at a certain period of the disease, but at 



RUBEOLA. 49 

the commencement, when the usual symptoms of measles 
are wanting, they may easily be mistaken for each other. 

Finally, the various inflammations which may be compli- 
cated with measles, may be recognised by their own peculiar 
characters, but it is to be observed that their march is often 
insidious and demands strict attention. 

Prognosis. — Rubeola is not usually a fatal disorder, but may 
become so in many cases; it is to be particularly dreaded in 
pregnant or recently delivered women and persons worn down 
by previous disease. In drawing a prognosis, the general cha- 
racter of the prevailing epidemic should be taken into the ac- 
count, and great attention paid to the degree of violence of the 
concomitant affections, and the nature of the organs impli- 
cated. The appearance of petechias, the eruption being pre- 
mature, its sudden disappearance with much fever and oppres- 
sion, are bad signs. 

Treatment. — Diet, rest, a mild temperature, warm diluent 
and mucilaginous drinks, inhalation of emollient vapours, and 
guarding the eyes from too vivid a light, constitute the treat- 
ment in ordinary cases of measles. 

The use of emetised drinks, administered either to favour 
the appearance of the eruption, or to relieve gastric disorder, 
is at least useless and often dangerous; the nausea and vomit- 
ing experienced by patients disappear in a majority of instances 
with the other symptoms, and even if they do not, palliatives 
and blood-letting are much preferable. The constipation which 
exists during the first days of the attack isof little consequence, if 
it remains for any time, it may be relieved by simple injections. 

If the eruption does not appear freely, or suddenly fades, 
diaphoretics should be employed, the patient should be put in 
a warm bath, in which a small quantity of flour of mustard 
had been mixed, or, what is preferable, a vapour bath, if it 
can be procured, administered. 

But when the eruption is tardy in its appearance, and at the 
same time the febrile symptoms increase, there is reason to ap- 
prehend the development of some organic inflammation, which 
should be immediately combated. 



50 EXANTHEMATOtJS DISEASES. 

We will briefly pass in review the best therapeutic means 
for this purpose. 

Blood-letting, both general and local, holds the first place. 
In making use of this remedy, the symptoms which belong to 
the disease itself and decline with it, must be distinguished 
from those of the concomitant malady, which always com- 
promit the life of the patient in a greater or less degree. Thus 
during the eruption there is always great excitement, thoracic 
pains, the cough becomes very troublesome, the oppression 
augments, and auscultation discovers a subcrepitating rattle of 
various degrees of strength; nevertheless, all these alarming 
symptoms disappear spontaneously with the striking out of 
the eruption. But if they should continue, recourse must be 
had to general or local blood-letting; the quantity of blood to 
be drawn must depend on the strength of the patient and the 
nature of the symptoms. 

Before the appearance of the eruption, if there are evident 
signs of pneumonia, or symptoms of gastro-intestinal inflam- 
mation, or if coma, stertorous respiration, and high fever exist, 
the patient must not be abandoned to the efforts of nature, but 
resort must be had to bleeding. 

In young children, the application of a few leeches to the 
temples, behind the ears, to the epigastrium or anus, will ad- 
vantageously supersede the necessity of phlebotomy. In adults 
and young persons, it is often useful to employ both general 
and local bleedings at the same time. It often happens, that, 
in consequence of bleeding in such cases, the eruption will 
make its appearance, and the dangerous symptoms diminish 
in violence. The precise time at which blood-letting is to be 
had recourse to, is of importance, as this means will be more 
efficacious as it is practised towards the commencement of a 
concomitant inflammation, if employed at a later period, when 
the system is sinking under the violence of the disease, and 
the different organs have been labouring for some time under 
great congestion, it is far from being useful, and may even 
hasten death. In fact, the use of blood-letting is to subdue 
those inflammations which so often aggravate the original dis- 
ease, and not to combat the eruption. 



RUBEOLA. 51 

Purgatives have been too highly praised by some authors 
in the cure of measles; gastro-intestinal inflammation so often 
occurs in it, that caution should be used in their employment. 
Nevertheless these remedies may produce very advantageous 
effects in cases of meningoencephalitis, pneumonia, violent 
angina, and croup; they should be employed conjointly with 
blood-letting. The purgatives generally used are senna, jalap, 
calomel, castor oil, &c. 

Towards the ninth or tenth day, if the ordinary diar- 
rhoea does not occur, it is adviseable to administer a mild pur- 
gative. 

The use of emetics should be restricted to those cases of 
measles, where they are complicated with croup. It must, 
however, be remarked, that in some instances the administra- 
tion of a few grains of ipecacuanha has caused the appearance 
of the eruption much more rapidly and strongly. 

Sinapisms and vesicatories should be employed with cau- 
tion, they may be useful in some cases to reinduce the appear- 
ance of the eruption. 

Lotions of cold water, where the skin is hot and dry, have 
been much commended by some celebrated English practition- 
ers. We will speak of their use, when treating of scarlatina. 

As to tonics, such as generous wine, cinchona, camphor, &c. 
they are only applicable to some exceedingly rare cases, and 
their employment requires great skill. They may be resorted 
to when the pulse is small and feeble, the skin cold, and the 
eruption pale or livid. They should never be used in cases 
where the skin is dry and burning, notwithstanding there may 
be adynamic symptoms. 

During the convalescence, the patient should take warm 
baths, guarding against taking cold; if the cough continues, 
laxatives, opiates, or blisters on the chest or the internal part 
of each arm, should be prescribed. Sometimes a slow fever 
remains, calling for constant care and attention. Finally, in 
cases of obstinate diarrhoea, opiates, demulcents, strict regi- 
men, and a blister on the upper part of each thigh, or on the 
ileo-coecal region, may all prove advantageous. 



52 EXANTHEMATOUS DISEASES. 

SCARLATINA. 

Scarlatina is a contagious disease, presenting itself in the 
form of small red points, which are soon replaced by large ir- 
regular patches of a raspberry colour, which, in becoming con- 
fluent, cover a great part of the body. A greater or less de- 
gree of fever, and of irritation of the mucous membrane of the 
mouth and larynx, precedes and accompanies the eruption. 

It is usually from the third to the sixth day after exposure 
to the contagion before the disease developes itself. 

Symptoms. — As regards the violence of the symptoms, this 
disease offers many varieties; they may be very light, whilst 
at other times they are extremely severe, and in numerous in- 
stances are complicated with others of so dangerous a charac- 
ter as to threaten the life of the patient, whom the best regu- 
lated treatment will not always save. 

Scarlatina generally commences in the evening, and in a 
sudden manner, with an access of fever, accompanied with de- 
pression, transient chills, nausea, and pains in the loins and 
lower extremities. The pulse is much accelerated, beating 
from an hundred and twenty to an hundred and forty strokes 
in a minute; the respiration is frequent and irregular. The 
skin of the body is hot, whilst the feet are cold; in some cases, 
though rarely, there are convulsions. 

The next day, or even during the night, the eruption ap- 
pears occupying at first the neck and face, but spreading over 
the whole body in the succeeding twenty-four hours. It con- 
sists of a multitude of small red points, so contiguous to each 
other, that the skin presents a universal red hue, and feels 
rough to the touch. This membrane is at the same time 
the seat of a violent heat, accompanied with great itching. 
Large patches of a raspberry scarlet colour cover all those 
parts of the body on which it rests; the colour is also deeper 
in the folds at the articulations. Not only the skin, but the 
tongue, pharynx, palate, interior surface of the eyelids, nos- 
trils, and cheeks, are also of a scarlet red at this time, and de- 
glutition is very painful. 



SCARLATINA. 53 

In many cases, the edges and extremity of the tongue are 
alone affected with this colour, whilst its surface is covered 
by a whitish mucous coat, through which the papillae appear 
more or less prominently and of a vivid red. 

The eruption is generally accompanied with a greater or 
less degree of excitement; sometimes there is delirium and 
coma, and often swelling of the face and extremities. In some 
cases, the febrile action diminishes on the appearance of the 
eruption, but it ordinarily continues as well as the other 
symptoms, as an ardent thirst, great heat, nausea, constipation, 
and more or less difficulty in deglutition. 

The raspberry colour of the eruption is always higher in 
the evening, and particularly about the third or fourth day; it 
begins to diminish on the fifth, and disappears towards the 
seventh, when desquamation takes place. 

The various symptoms that accompany the eruption, disap- 
pear with it; deglutition becomes easy, but the redness of the 
tongue remains; at this time, a copious perspiration or diar- 
rhoea often occurs, and the urine deposits a sediment, which, 
in some cases, is very abundant. The desquamation, at 
times furfuraceous, often lamellar, is accompanied with a very 
troublesome itching, and takes place several times, fS. sim- 
plex, Willan.) 

Such is the course of the mildest variety of scarlatina, the 
duration of which is from eight to ten days. But in other 
cases, the fever is more violent, and the angina much more 
dangerous; it is the predominance of this latter symptom that 
has given the name of anginose scarlatina to this variety* 
(S. anginosa, Willan.) 

In this form of the disease, the angina often precedes the 
fever, and the premonitory symptoms of the eruption are far 
more violent than in simple scarlatina. The patient experi- 
ences at first, a sudden sensation of stiffness of the muscles of 
the neck and lower jaw, and the mucous membrane of the 
pharynx presents a vivid red colour. General symptoms ra- 
pidly develope themselves on the second day, the tonsils are 
much more swelled, the voice becomes hoarse, deglutition is 

8 



54 EXANTHEMATOUS DISEASES. 

painful and difficult, sometimes impossible; in which case, 
drinks are rejected through the nose, respiration is more or 
less impeded, and excites a painful feeling of constriction m 

the throat. 

The other symptoms are a great frequency of the pulse, 
violent heat of the skin, excitement, cephalalgia, coma, slight 
delirium, nausea, and sometimes vomiting. 

The eruption in this variety presents much the same ap- 
pearances as in simple scarlatina, but does not always appear 
on the second day, being sometimes retarded till the third. It 
is also less generally diffused, and is composed of large, irre- 
gular scarlet patches on different parts of the body, but particu- 
larly on those onwhichit reposes. In many cases, the soft palate, 
the tonsils and pharynx, are covered with a thick mucous se- 
cretion, or with flakes of a grayish-white pultaceous matter, 
which, in some instances, adheres for days, and in others is 
renewed from day to day. Ulceration of the tonsils does not 
generally occur, but sometimes these glands are slightly al- 
fected, as are also the soft palate and the posterior portion ot 
the pharynx. The pultaceous secretion may be of a black 
colour, from admixture with extravasated blood; the tongue 
and lips are often parched and chapped, and the blood in dry- 
ing on them, forms black crusts. 

In this form of the disease, the eruption often disappears in 
the course of twenty-four hours, and returns in an irregular 
manner, both as to situation and time of attack. The general 
symptoms are, however, rarely aggravated, but the duration 
of the disease is prolonged, and the desquamation less re- 
gular. 

In mild cases, this sometimes is wholly wanting, whilst in 
others, it continues for three or four weeks. Although there 
may exist a variety of degrees in this form, we have content- 
ed ourselves with detailing the most prominent symptoms. 
The angina is the most obstinate. 

Scarlatina also puts on a much more dangerous form, and in 
such cases has received the name of malignant, (S. maligna, 
Will.) but it must be observed that all these varieties are only 



SCARLATINA. 55 

different degrees of severity in the attack; and that, although 
it may be very light during the first few days, it may after- 
wards assume a malignant type. 

Scarlatina maligna at first presents the same symptoms 
as the preceding, but on the second or third day, dangerous 
appearances occur. The eruption usually takes place in 
twenty-four hours, but is sometimes later. There is much de- 
pression, an ardent thirst, dryness and burning heat of the 
skin, much restlessness, oppression and vomiting; the pulse 
is full and frequent. After some hours, the symptoms aug- 
ment in violence, excitement and delirium supervene, the 
tongue becomes dry, the pulse loses its force, but not its fre- 
quency; the skin remains hot, the eyes are injected, the 
cheeks of a crimson red colour, the breath fetid, and the ton- 
sils and surrounding parts covered with a blackish secretion. 

In children there may be coma, stertorous respiration, swell- 
ing of the neck, throwing of the head backwards, and an ex- 
tremely rapid but scarcely perceptible pulse. Sometimes 
haemorrhage, either from the nose or intestines takes place, or 
a petechial eruption, the extremities become cold, and the 
patient expires. This fatal termination often occurs without 
the eruption having disappeared or faded, and in some cases 
the burning heat of the skin continues to the last. 

This form of the disease may terminate, as we have just ob- 
served, by death, which may take place in a few hours, or 
days, or even later. Even if the patient survives, the succeed- 
ing symptoms may be dangerous. These are gastro -intestinal 
inflammations, and abundant suppuration following the eschars 
which have formed in different parts of the body. 

Other cutaneous eruptions may be complicated with scarla- 
tina. There is often a miliary eruption which covers the tho- 
rax, temples, neck, scalp, and shoulders; this soon disappears, 
either from the absorption or effusion of the fluid contained in 
the vesicles. Combinations of scarlatina with measles, erysi- 
pelas, and small-pox, are more uncommon. 

Violent attacks of scarlatina are generally accompanied 
either with inflammation of the brain, of the thoracic viscera, 



5G EXANTHEMATOUS DISEASES. 

or of the gastro-intestinal mucous membranes. Oftentimes all 
the large viscera appear to be simultaneously affected, and na- 
ture, overwhelmed by the violence of the disease, soon suc- 
cumbs. The partial gangrenes which occur in certain cases, 
announce great disorder of the circulation. 

Abscesses of the tonsils, bronchitis, ophthalmia, otitis with 
deafness, swelling of the parotids, inflammation of the testicles 
in adults, and engorgements of the sub-maxillary and inguinal 
glands in children, are often the sequelae of this disease. It is 
sometimes followed by a state of great weakness: but the symp- 
tom most to be dreaded during the convalescence, is acute ana- 
sarca, and serous effusions in the different splanchnic viscera. 
The anasarca may be either partial or general; it occurs eight 
to ten days after the disappearance of the eruption, particularly 
where this has been very extensive. It has been remarked 
that this occurred more frequently and violently in children 
than in adults, in winter than in summer, and that cold and 
humid weather exercised a great influence in its development. 
Its precursory symptoms are lowness of spirits, general lan- 
guor and depression, loss of sleep and appetite; the pulse be- 
comes frequent and chorded, the skin hot, and the urine 
scanty and turbid. The oedema commences in the eyelids, 
then attacks the face and inferior extremities: it may be uni- 
versal; its duration is from six to twelve days, and it is unac- 
companied with danger when it is confined to the subcutane- 
ous cellular tissue. It may be complicated with diarrhoea and 
symptoms of gastro-intestinal irritation. In some rare cases, 
sudden effusions take place in the serous cavities, and occasion 
death in a short time. 

Dissection. — In persons who have died of scarlatina, the 
skin presents large patches of a livid, red colour, occupying 
the superficies of the dermis, and, as in all inflamed tissues, 
putrefaction of this membrane rapidly ensues. The mouth, 
nasal fossae, pharynx, and even the trachea, are usually red, 
and covered with a greater or less quantity of grayish, pulta- 
ceous matter. In a majority of cases there exists a marked in- 
jection of the brain, and of the vessels which ramify over its 



SCARLATINA. 57 

surface. Sometimes the lungs are sound; at others, they are 
gorged with blood, and easily torn; in some cases, however, 
their tissue is dense and solid, of a vivid red, and very firm 
and tough. The mucous membrane of the stomach generally 
appears injected. That of the intestines is often reddened, even 
in those cases where diarrhoea has been one of the predominant 
symptoms. 

Causes. — Scarlatina is occasioned by an unknown conta- 
gious principle; children and young persons are more usually 
attacked than adults; it seldom affects an individual more than 
once, and in two thousand cases, Willan never met with an 
instance of a recurrence of the disease. When this affection 
is epidemic, it appears that the specific cause sometimes de- 
velopes certain anomalous characters, such as the general symp- 
toms without eruption, or vice versa. In the first case is it 
really scarlatina? 

This disease is not confined to any season; it may reign epi- 
demically during all; but it generally appears in the autumn, 
after heavy rains, followed by warm weather. The situation 
of certain spots in vallies, and the middle of woods, or in ge- 
neral, whatever tends to diminish the free circulation of air, 
appears to the development of this disease. It must also be 
noticed, that persons who have been affected with scarlatina, 
may propagate the disease during the whole period of desqua- 
mation; in fact, it appears that the contagion is most active at 
this epoch. 

Diagnosis. — Scarlatina can never be mistaken for measles, 
if it be recollected that in the former the eruption usually mani- 
fests itself in twenty hours after the appearance of the first symp- 
toms. The extent and raspberry hue of the eruption, and the 
nature of the symptoms of irritation of the mucous membranes, 
which, in scarlatina, principally affects the pharynx, will pre- 
vent all misapprehension. 

In roseola there is often sore throat, but the eruption never 
presents large patches as in scarlatina; the shade of colour is 
not the same; the duration is short, and the course often ir- 
regular. 



58 EXANTHEMATOUS DISEASES. 

Prognostic. — Scarlatina, when it is simple, is in general un- 
accompanied with danger, not more so than measles. The 
two latter varieties, however, are often fatal. It is always to 
be dreaded when it attacks either pregnant women, or those 
recently delivered, and when it is accompanied with other 
dangerous diseases. 

Treatment. — When scarlatina is slight, attention, and the 
simplest antiphlogistic remedies are all that are required; a 
moderate temperature, diet, refreshing mucilaginous drinks, 
acidulated with either lemon-juice, the hydrochloric, or any 
other acid, (for this latter does not appear to possess the spe- 
cific qualities that have been assigned to it,) emollient and 
slightly tonic gargles form all the necessary treatment. The 
constipation which exists the first few days, should be reliev- 
ed by simple injections. 

It is not necessary to administer emetics at the commence- 
ment, the nausea and vomiting rather indicate gastric irrita- 
tion, than a saburral condition of the alimentary canal. 

To these means, although sufficient for simple scarlatina, 
other and more energetic treatment must be added in the an- 
ginose and malignant forms of the disease, especially if there 
also exist symptoms of inflammation of one or more of the in- 
ternal organs. 

Blood-letting, above all, is indicated in these cases. One or 
more applications of leeches to the anterior part of the neck, . 
when the angina is violent, produces great relief, as also does 
topical detraction of blood from the epigastrium, when there is 
nausea and obstinate vomiting, accompanied with pain in this 
region. General bleedings, ordinarily useless in the simple 
form of the disease, may be used with great advantage when 
scarlatina appears in young persons, strong and muscular 
adults, and females near the time of their delivery. In these 
cases, one or more large bleedings, practised at the commence- 
ment, will prevent or diminish danger. In malignant scarla- 
tina, where the course of the disease is very rapid, the symp- 
toms becoming alarming in a few hours, this remedy must be 
had recourse to very early, for, if congestion takes place in 



SCARLATINA. 59 

the different organs, it becomes very difficult, or almost im- 
possible to relieve them. At a more advanced stage of the dis- 
ease, much less reliance should be placed on blood-letting, 
which, when employed at such a time to combat the symp- 
toms, even where it seems well indicated, is often useless, and 
sometimes hurtful. Finally, blood-letting is most efficacious 
where there is inflammation of one or more of the important 
organs, thus leeches should be applied to the neck and the mas- 
toid apophyses, if symptoms of cerebral congestion exist, and 
they should be resorted to early. 

Laxatives and purgatives are at best useless, in simple scar- 
latina, where it pursues a regular course, but when there are 
symptoms of either cerebral or pulmonary congestion, they 
should be freely used, conjointly with bleeding. Their use is 
also beneficial when the angina is violent. In their adminis- 
tration, no guide can be drawn from the redness of the tongue, 
as this colour, which is often scarlet, analogous to that of the 
skin, is a symptom of the disease. In cases where the signs of 
gastric irritation are strongly developed, it would be better to 
make use of injections. 

Emetics are only indicated in those cases where it becomes 
necessary to free the pharynx from the viscid secretions which 
clog it; this occurs principally in children. 

Effusions with cold water, although not employed in 
France, have been used in England by the most celebrated 
practitioners. This remedy, which has erroneously been sup- 
posed very dangerous, has been adopted in several epidemics 
of scarlatina, particularly when the eruption had arrived at its 
greatest height. When this has moderated, simple sponging 
with vinegar and water is to be used. The results are in ge- 
neral beneficial; there is a marked diminution of the heat, of 
the quickness of the pulse, and other symptoms. The fear of 
danger from this remedy is not founded on any fact, and it is de- 
sirable that recourse should be had to it in cases where the 
disease presents itself with the violent symptoms it some- 
times offers. In simple cases, it may be sufficient to lightly 
sponge the different parts of the body, and particularly the 



60 EXANTHEMATOUS DISEASES. 

forehead, face, and arms with cold water or vinegar. Some 
pathologists have objected to the employment of this remedy, 
that it might favour the development of anasarca, as during 
the convalescence from scarlatina, this symptom is generally 
induced by the action of cold. This reasoning does not appear 
to us as just, for the influence of cold during the inflammatory 
stage of scarlatina need not produce the same effect as during 
the convalescence. Besides, in what manner can the two im- 
pressions be compared? 

The use of sinapisms, of blisters, and other irritating appli- 
cations ought to be restrained to those cases where it becomes 
necessary to establish a powerful revulsant. The application 
of blisters to the front part of the neck in those cases where 
there is violent angina, only adds to the irritation of the skin, 
without being of advantage to the interior inflammation, in 
some instances it has induced gangrene. 

The convalescence demands curative means, as warm baths, 
&c. In cases of obstinate constipation, if there should be no 
counter-indication, mild laxatives may be given. The patient 
should avoid exposure to cold air or any deviation from his 
regimen. If anasarca takes place, it must be combated with 
rest, diet, and warm diaphoretic drinks; if there is much fever, 
diarrhoea, or gastric symptoms, leeches should be applied 
either to the anus or epigastrium; vapour baths are also very 
efficacious in anasarca. 

Belladonna has been proposed as a prophylactic against 
scarlatina, and has been employed with success of late years, 
in several epidemics, both in Germany and Switzerland. Dr. 
Biett has observed this disease in an epidemic form in one of 
the elevated valleys of the latter country, in which all the 
children to whom belladonna had been administered, were, 
without exception, exempt from the disease. No hesitation 
should therefore take place in its administration, when the 
scarlatina makes its appearance in schools, &c. or wherever it 
occurs epidemically. 

The most commodious preparation, and the form in which 
it appears to act with the greatest efficacy, is the tincture. 



URTICARIA. 61 

The usual dose is six drops a day to children of eight or ten 
years of age: it need scarcely be added, that it must be aug- 
mented or diminished, according to the age of the patient. 
Its use must be persisted in, for ten or twelve days. It is 
well ascertained that in the small number whom it did not 
protect from the disease, this was always mild, and of a short 
duration.* 

Urticaria. Nettle-rash. Fievre OrttSe. Porcelaine. 

Urticaria is a non-contagious cutaneous inflammation, cha- 
racterized by prominent patches of various forms and extent, 
but generally irregular, of either a redder or whiter colour 
than the surrounding skin, usually very transient, and some- 
times accompanied by an intolerable itching. 

The nettle-rash, though sometimes acute, is ordinarily chro- 
nic, and its duration varies from two or three days, to months 
or even years. That of acute urticaria is from eight to ten 
days, but no limits can be assigned to the chronic form. As 
to the individual duration of the patches, it varies from a few 
minutes to twelve or twenty-four hours, but in some rare 
cases, they last for one or two weeks. (U. perstans.) 

Causes. — Attacking all ages, both sexes, manifesting itself 
at all seasons, the nettle-rash, however, particularly affects 
children, young persons, females, and individuals of a san- 
guine and nervous temperament. It is observed most fre- 



* No remedy has been more highly praised in scarlatina than belladonna, 
particularly by the German physicians. The following- prescription was 
used by Dr. Maisier with almost universal success as a preventive in epi- 
demic scarlatina: — 

Extract of fresh prepared belladonna, gr. xv. 

Dissolve in fennel water, 3V. 

Add rectified alcohol, gi. 

The dose is to be a drop for every year of the age of the child, never, how- 
ever, exceeding fifteen drops. It is to Hahnemann we owe this discovery, 
and it is highly praised by the celebrated Hufeland. But at the same time 
it must be mentioned that several physicians have given it a fair trial with- 
out success. — Thaws. 

9* 



d"2 EXANTHEMATOUS DISEASES. 

quently in the spring and summer. Some persons, in whom 
the skin is fine and delicate, are so predisposed to it, that the 
least pressure or chafing will induce large patches of urticaria, 
resembling the redness from flagellation. 

Urticaria may be induced by direct and appreciable causes, 
thus it is produced by the leaves of the nettle, ( U7 y ticadioica,J 
by the contact of certain caterpillars, &c. * In these cases the 
eruption is always local and often ephemeral. At other times, 
without being able to trace it to its probable causes, it appears 
to be developed during dentition, by states of mental excite- 
ment, abuse of the pleasures of the table, and above all by the 
ingestion of certain articles of food, as mushrooms, almonds, 
honey, cucumbers, &c. But the substances which appear to 
possess this property in the highest degree are muscles, crabs, 
and some kinds of dried, salted, or smoked fish. It is gene- 
rally attributed in these latter instances to a certain degree of 
putrefaction of these animal matters, but this is far from being 
proved, for among several persons who may partake of them, 
only one may be affected, pointing out a particular predisposi- 
tion, which is sometimes so evident, that there are many per- 
sons who cannot under any circumstances make use of these 
articles without inducing an attack of urticaria. 

This eruption sometimes accompanies intermittent fever, or 
irritation of some internal organ. It may also coexist with dis- 
eases of the skin wholly different from it, particularly with 
Lichen simplex. In some instances it is connected with a pe- 
culiar and unknown state of the system. 

Symptoms. — The course of this eruption is extremely irre- 
gular, being sometimes accompanied with general symptoms, 
but in most cases presenting only those that are peculiar to it; 
it may disappear and return several times for days or even 
weeks, leaving but short intervals between its attacks, till it 

* Dr. Hewson mentions several cases of eruption, induced by the inges- 
tion of Bals. Copaiba, (North American Medical and Surgical Journal, Vol. 
V. p. 72,) some of which resembled urticaria, whilst others assumed the ap- 
pearance of erythema or roseola. Urticaria is sometimes produced from eat- 
ing strawberries. — Trans. 



URTICARIA. 63 

finally ceases; at other times it lasts for a certain time, but in 
the plurality of instances it ceases and reappears at irregular 
periods, and thus continues for months and years. We have 
seen several cases of chronic urticaria in the hospital, which 
had lasted for more than a year. 

Urticaria has been divided into many varieties, according 
to its form, its symptoms, &c. of which the following are the 
most important. 

1. Urticaria febrilis. (The true fievre ort iee. ) The erup- 
tion is preceded several days by head-ache, nausea, pains in the 
epigastrium and anxiety; it is accompanied with slight horripi- 
lations; it commences by a general itching, with a sensation of 
heat over the whole body, the least touch will occasion red or 
whitish elevations, surrounded by a vivid red or crimson 
areola, particularly on the shoulders, loins, internal part of 
the forearm, thighs, and around the knees. These are promi- 
nent and sometimes circular, but generally irregular, their 
edges are hard and their size variable, being confluent in some 
places; the limbs then appear swelled, and the skin presents 
an almost universal red hue. ( U. conferta, Will. ) An intole- 
rable itching and tingling accompany the eruption, and give 
the patient but little rest. The itching is much augmented 
by the heat of the bed. The eruption does not continue during 
the whole of the disease, which is of seven or eight days du- 
ration from the period of attack; but appears and recedes ir- 
regularly on every part of the body, and its return, which is 
generally towards evening, is accompanied with a slight ac- 
celeration of the pulse. The patient can often produce it at 
will on any spot by scratching. The predominant symptoms 
during the continuance of the disease are languor, .anorexia, 
fever, and a greater or less degree of gastric irritation. These 
symptoms gradually disappear, and the eruption insensibly di- 
minishes until at last there is a mere itching left, finally it 
ceases entirely, and in some cases where it has been very 
strong and general, it is succeeded by a slight desquamation. 

Urticaria, produced by the ingestion of the substances for- 
merly alluded to, belongs to this variety. In these cases it 



64 EXANTHEMATOUS DISEASES. 

ma)> r manifest itself in a few hours, but it usually appears on 
the succeeding day. The patient generally experiences, one 
or two hours after the ingestion of these articles, an uncom- 
fortable feeling, weight at the epigastrium, vertigo, nausea, 
and general prostration, the skin soon becomes hot and the 
eruption appears. The symptoms are much the same as those 
above described, except that they are often accompanied with 
vomiting and alvine dejections, the eruption is more general; 
it is in these cases that the patches become confluent, that there 
is swelling and stiffness, the face especially is oftentimes much 
tumefied, and the itching is insupportable. In some instances 
the urticaria is complicated with erythematous patches of a large 
size. Finally, this variety, which generally diminishes in 
violence at the end of thirty-six or fortjr-eight hours, and short- 
ly afterwards disappears, leaving slight traces on the skin, may 
also in some rare cases, terminate in death. But it may readily 
be supposed that this event, should rather be attributed to the 
deleterious action of the ingested article, than to the violence 
of the eruption. 

2d. Urticaria evanida. — This variety is completely chro- 
nic. The eruption appears at irregular periods, sometimes in 
one place, sometimes in another, but may be confined to one 
region. It is not attended by fever, and usually disappears in 
a few hours. The patches, rarely rounded, are generally ir- 
regular, and resemble those produced by flagellation. They 
are not accompanied with an erythematous areola, and present 
no other symptom than that of a violent itching. The urtica- 
ria evanida ordinarily lasts for several months, and may even 
be prolonged for whole years. This is the form generally ob- 
servable in females and in persons endowed with great suscep- 
tibility of skin. It often resists the most skilful treatment, and 
in a multitude of cases appears to be connected with some al- 
teration of the digestive organs, and particularly of the sto- 
mach. At the same time we frequently see this disease in per- 
sons enjoying the most perfect health. 

In some instances, the itching is replaced by a sense of 
pricking under the skin, which is very acute and resembles 



URTICARIA. 65 

that produced by a needle thrust into the skin. (U. subcu- 
tanea, Willan.) This pain, the only appreciable symptom, 
never is accompanied with an eruption, and it is only at ex- 
tremely distant intervals that spots appear. This variety ap- 
pears to be specially induced by strong mental emotions, or 
by a sudden change of temperature. 

3d. Urticaria tuberosa, (Franek, Will.) — In this form, 
which is the rarest, the disease is of a violent character. There 
are not only somewhat prominent patches, but real tuberosi- 
ties of greater or less extent, which are hard, deep-seated, and 
accompanied with difficulty in the movements, and violent 
pain and tension. It usually appears in the evening or night, 
and disappears the next day, leaving the patient prostrated, 
weak, restless, and complaining of general lassitude. It some- 
times appears with still more severe symptoms. Thus, at the 
Hospital of St. Louis, in a patient in Mr. Biett's wards, we have 
seen it accompanying a quotidian intermitting fever, and after 
having lasted for four years, finally induce swellings and great 
distention, ecchymoses, ruptures, and ulcerations. In many 
paroxysms it was accompanied with a general tumefaction, 
sometimes to such a degree that the patient was nearly suffo- 
cated, his respiration was hurried, the movement of the thorax 
very slight, the neck swelled, the face puffed up and of a vio- 
let colour, the pulsations of the heart intermitting and at times 
scarcely perceptible, and death, which appeared imminent, 
only prevented by large bleedings. This patient, who had 
passed through several hospitals, and in which every means of 
cure had failed, was at last restored to health by the use of 
Fowler's solution.* 

The urticaria tuberosa appears to be produced by excess 
in food, or by the excessive use of spirituous liquors. Its du- 
ration, which, as we have stated, may be for several years, is 
ordinarily of several months. 

Diagnosis. — The form and elevation of the patches, the 

* For a detailed account of the case, see Nouv. Bib. M£dicale. Oct. 1827, 
Bulletins de l'Athenee, page 62. 



qq EXANTHEMATOUS DISEASES. 

great itching, the ephemeral character of the eruption, are 
symptoms sufficiently characteristic to prevent this disease 
from being mistaken for any other exanthemata. 

In the lichen urticans, which may be confounded with 
some cases of urticaria, the papula are round, much smaller, 
and less elevated; their colour is also darker, they are more 
resisting to the touch, never disappear spontaneously, and 
always present in their vicinity the real signs of lichen; true 
papula^ which need only be seen once, to distinguish them 
from the eruption of nettle-rash. 

The urticaria tuberosa may* under some circumstances, 
be confounded with erythema nodosum. The acute, conti- 
nued, and permanent character of the latter will always suf- 
fice to distinguish it from this severe variety of urticaria, 
which presents very different symptoms. 

Nettle-rash sometimes exists, conjoined with other erup- 
tions, as erythema, often with roseola, and in some cases, 
with impetigo and lichen. 

Prognosis.— Urticaria is seldom dangerous of itself. 1 he 
urticaria tuberosa is the only form in which it is serious; but 
it constitutes a painful and annoying disease, from its intoler- 
able itching and obstinate character. 

Treatment.— Urticaria, which is the result of direct causes, 
requires no medical treatment in a majority of cases. Acidu- 
lated local applications,one or two tepid baths,and weak lemon- 
ade, are the only means to be employed if the eruption does 
not speedily subside. Lotions with a solution of acet. plumbi, 
or subcarbonate of potash, or baths rendered alkaline by the 
addition of this salt, are sometimes necessary to allay the vio- 
lent itching, particularly where the eruption has been pro- 
duced by contact with certain caterpillars. The simple febrile 
nettle-rash yields readily to a strict diet, cooling drinks and 
tepid baths. Mild laxatives are sometimes useful, particularly 
where the disease accompanies dentition But where it is the 
result of the ingestion of certain articles of food, vomiting must 
be induced, if it should not have taken place. Afterwards 
strongly acidulated drinks should be given, (barley water, 



URTtCAHIA. 67 

with a drachm of sulphuric or nitric acid to the pint,) or 
sweetened water, and every half hour thirty to forty drops of 
ether on a piece of sugar. 

Chronic nettle-rash is much more difficult to eradicate; a 
strict regimen must he insisted on, taking care to avoid any 
thing that appears to exercise an influence on the development 
of the disease. In some cases it is beneficial to make an entire 
change in the habits of the patient. Blood-letting, either ge- 
neral or by the application of leeches to the anus, is useful 
in young and plethoric persons, or in women who are irregu- 
lar in their menstruation. Simple tepid baths produce less 
effect, where the disease has lasted for some time, than alka- 
line or vapour baths, or even partial applications of vapour, 
when they affect a particular part. In all cases, acidulated 
drinks, and some mild laxatives, are the best adjuvants to the 
preceding. 

When nettle-rash accompanies intermitting fever, this latter 
disease must be particularly attended to. Here much success 
is obtained with the sulphate of quinine; it cures the febrile 
attacks, and in most cases the eruption disappears with them. 
If the cinchona fails, and the intermitting urticaria presents 
the alarming symptoms we have spoken of, recourse must be 
had to Fowler's solution.* 

* To relieve the excessive itching, where recourse cannot be had to the 
medicated baths, the patient should be liberally dusted with well-toasted 
rye or wheat flour, and scratching avoided as much as possible. Dr. De^ 
wees has found the Fowler's solution to succeed in a majority of chronic 
cases. The dose for a child of from seven to fourteen years of age, is four 
drops, three times a day, in sweetened water; if this sickens, decrease the 
dose to two or three drops.— tTrans. 



( 68 ) 

ORDER II. 

VESICULAR DISEASES. 
VESICULM. 

THE diseases arranged in this class are characterized by 
small elevations of the cuticle, formed by a collection of a 
transparent serous fluid. 

These elevations have received the name of vesicles; some- 
times they terminate by a loss of transparency, and assume a 
yellowish colour. The serosity may be re-absorbed, but it is 
generally effused over the surface of the skin, where it forms 
either whitish scales, or thin, yellowish, lamellar crusts. 

These diseases are different in their course; some are essen- 
tially acute, as varicella and miliaria; others, though some- 
times appearing in this form, are in general chronic, as ec- 
zema, herpes, and scabies. 

Their duration varies from a few days, to weeks, months, 
or even years. 

Symptoms. — Sometimes preceded in their appearance by 
general symptoms, as in the acute varieties, the vesicles suc- 
ceed an eruption of red spots, oftentimes of a very light co- 
lour, in the centre of which the cuticle soon becomes elevat- 
ed. At other times, on the contrary, they take place without 
being preceded or accompanied by any other symptom than 
an itching. The vesicles sometimes arise from a red and in- 
flamed surface, and at others do not present the slightest trace 
of an inflammatory areola. 

They may be small, acuminated, or globular; large, promi- 
nent, and irregular, or even flattened. In some cases they are 
distinct, in others they are conglomerated, and form large 
surfaces, which appear studded with an innumerable quantity 
of small, silver-white points. 



VESICULiE. 6i> 

They generally cover irregularly circumscribed surfaces of 
different sizes, and sometimes form semicircular bands or even 
rings. 

Seat. — The vesicular diseases may attack all parts of the 
body, and often cover the whole surface'; this occurs in the 
acute forms, as varicella, miliaria, and sometimes eczema; 
even scabies may in certain cases simultaneously affect every 
portion of the body. But eczema, herpes, and scabies, are 
usually confined to one or more regions, and at times to a very 
circumscribed spot. 

Causes. — Scabies is the only vesicular disease that is con- 
tagious, the others result from some inappreciable derange- 
ment of the system, but may be excited in some instances by 
the influence of external causes. 

Diagnosis. — The presence of vesicles, independently of 
the well-characterized symptoms peculiar to each species, will 
always prevent any mistake in the diagnosis; and although in 
certain cases some of the vesicular affections appear at the first 
glance to resemble the pustular diseases, there exists, never- 
theless, a very striking line of demarcation; the one always 
commences with vesicles, which, if they should lose their 
transparency, never contain a sero-purulent fluid, and are con- 
stantly accompanied with transparent vesicles, and finally, in 
concreting, the sero-purulent liquid only forms scales, whilst 
the other always begins by a real purulent eruption, accompa- 
nied with deeper inflammation, and terminates not in scales, 
but in thick crusts or scabs. 

Prognosis. — The vesicular affections are seldom serious; 
some among them, (the eczema acuta, Biett,) may however 
become so from their extent. 

They may terminate by resolution; the liquid which ele- 
vates the cuticle is re-absorbed, and a slight desquamation 
takes place; in this manner does miliaria, and in some cases, 
eczema, disappear. 2d. At other times the fluid concretes, 
and forms yellowish lamellar crusts: this is observed in ec- 
zema and herpes. 3d. The contained fluid is effused over 
an inflamed surface, which excoriates and secretes a serous 

10 



70 VESICULAR DISEASES. 

fluid, (eczema chronica.) 4th. In certain cases it forms true 
ulcerations, (zona. J 

Treatment. — The vesicular affections require very simple 
treatment. The antiphlogistics are the most proper remedies* 
in the acute forms. Those that are chronic, require a very 
active treatment, which, however, they sometimes resist for a 
long time. 

Miliaria. — Sudamina. Febris miliaris. 

Miliaria is a disease characterized by an eruption of vesi- 
cles about the size of a grain of millet, scattered in various 
numbers over a greater or less extent of surface, and which is 
in most cases the concomitant of some more serious disorder. 

Every part of the body may be the seat of these vesicles, 
but they are generally observable on the anterior or posterior 
part of the trunk. But they may occur on the limbs and 
face, although this is seldom the case. The eruption is usu- 
ally confined to particular spots; it seldom attacks the whole 
body. 

Causes. — The appearance of miliaria is always connected 
with some violent excitement of the integuments, and with 
profuse sweats. It has been observed as a concomitant symp- 
tom of a variety of gastro-intestinal affections, and its develop- 
ment usually coincides with the paroxysms. It is frequently 
seen in puerperal fevers, and above all when the serous mem- 
branes are affected. It also accompanies the sweating sick- 
ness, certain cases of rheumatism, and scarlatina. In some 
epidemics of gastro-enteritis, this eruption has always appear- 
ed as one of the symptoms. 

A stimulating treatment, or the use of tonics and excitants in 
these different diseases, seems to be the cause of miliaria, or 
at least to increase it; but these vesicles are also observed, 
where an active antiphlogistic treatment has been pursued, 
though in such cases the disease is less violent. 

Miliaria may ordinarily be regarded as symptomatic of some 
more serious disease, but there are instances where it is idio- 



MILIARIA. 71 

pathic, as when it occurs in persons in good health, after vio- 
lent exercise, during the heat of summer. 

Miliaria is attended in such cases with a feeling of heat and 
great itching, but the eruption is ephemeral, and a complete 
restoration to health takes place in twenty-four hours. 

Symptomatic miliaria may occur at all periods of the dis- 
ease which it accompanies, and return more than once. 

Sy7nptoms. — It is not preceded by any symptom in parti- 
cular, except an exacerbation of those of the principal disease. 
Generally, the appearance of the vesicles is attended by 
sweats, and a feeling of heat and itching in the parts in which 
it occurs. The vesicles are rarely confluent, but they often 
form patches of various sizes, or are grouped together irregu- 
larly. Their number is variable, sometimes a great part of 
the body is covered, and at others they are widely scattered. 

The vesicles, at first very small and transparent, are often 
developed on a vivid red surface, and this colour is then visi- 
ble through them, (Miliaria rubra.) In the space of twenty- 
four to forty-eight hours, the vesicles augment in size, and 
contain a milky fluid, which gives them a pearly appearance, 
(Mil. alba. J This is particularly striking in scarlatina, where 
a great number of these vesicles appear on a large surface, of 
a raspberry colour, they are soft to the touch, and soon disap- 
pear, either by the absorption of their contents, or by its effusion. 
Sometimes the cutaneous affection ceases by the desiccation of 
the vesicles, and at others, successive eruptions prolong the 
attack for one or two weeks. 

In certain cases of violent entero-colitis, accompanied with 
general debility, the miliary eruptions, which often occur at 
night during the paroxysms, present the next day a complete 
vesicular appearance, and the portion of skin which they 
cover is destitute of redness, it is as if a multitude of minute 
drops of limpid water had been sprinkled over its surface. 
These vesicles disappear in about twenty-four hours, and a 
slight desquamation of the cuticle succeeds. 

As to the diagnosis of miliaria, eczema is the only disease 
with which it can be confounded; it differs from it, however, 



72 VESICULAR DISEASES. 

by the circumstances under which it appears, by its rapid pro- 
gress, and short duration. Besides, in eczema the vesicles are 
confluent, and an immense number are visible in a very 
circumscribed space; whilst, in miliaria, the vesicles are al- 
most always isolated, and are larger than those in eczema. 

The prognosis of this disease is favourable; but is depend- 
ant on the violence of the malady it may accompany, and the 
appearance of it usually announces a state of general excite- 
ment, without in itself being dangerous. 

Miliaria demands no treatment, it is the general disease that 
must be attended to, and it may be safely asserted, that anti- 
phlogistic means are the best adapted to these cases.* 

Varicella. — Chicken-Pox. Swine-Pox. 

By this name is meant a non-contagious disease, charac- 
terized by an eruption of vesicles in various numbers; the ap- 
pearance of which is preceded or accompanied with general 
symptoms, and whose desiccation happens from the fifth to 
the eighth day. 

Questions of the highest importance have latterly arisen, as 
regards chicken-pox, and it appears necessary, before giving 
a description of this disease, to enter into some details on the 
subject. 

The name of varicella, or jietite verole volante, had been 
given to slight and purely vesicular diseases, to distinguish 
them from small-pox, with which they were thought to pos- 
sess a strong resemblance, and to be mere varieties. More re- 
cently these diseases were wholly separated from each other, 
as differing in symptoms and causes. Never, it is said, are 
the symptoms of varicella similar to those of small-pox, and 
never is the cause of variola that of chicken-pox. These 
striking differences were sufficient to establish a marked line 

* Miliaria is now a disease of rare occurrence, but appears to have been a 
very common attendant on febrile attacks, during the time they were treated 
on a heating - and stimulating- plan; hence, its frequency in puerperal fevers, 
as mentioned by White, Cullen, and others. — Trass. 



VARICELLA. 



of demarcation between the two diseases, and, according to 
those who established these distinctions, nothing was more 
easy than to distinguish the two affections. But experience has 
not demonstrated the validity of these assertions, for we ob- 
serve, in the long discussions on inoculated small-pox, that 
very able practitioners give the name of varicella to affections, 
which, according to others, are true variola. Far from being 
decided by the discovery of vaccination, these disputes on the 
nature of varicella have become more extensive; and, at this 
time, the opinion of practitioners is far from being fixed, on 
this important question. 

Among the authors who have been prominently engaged 
in this discussion, some, as Thomson, Berard, Delavie, &c. 
maintain, that the chicken-pox should not be separated from 
variola, of which it is but a variety, for, according to them, 
the cause is the same. Others, as Luders, Abercromby, 
Bryce, &c. in admitting that certain variolous affections have 
been wrongfully admitted as varicella, assert, that this latter 
disease should be distinguished from variola, and that it con- 
stitutes a distinct affection, not only in the nature of its symp- 
toms, but in its cause. 

We shall rapidly review the facts and arguments advanced 
by these writers in support of their opinions, and shall after- 
wards point out the reasons that induced us to describe the 
chicken, as distinct from the small-pox. 

Thomson having observed during variolous epidemics, that 
vesicular eruptions, similar to those of varicella, were simul- 
taneously developed, and under the influence of the same 
causes as those of small-pox, both in vaccinated persons, or in 
those that had formerly had the small-pox, was naturally led 
to suppose that these eruptions had the same cause, and should 
be considered as varieties of the same disease. 

In these epidemics, as in those we have latterly observed in 
Paris, the eruptions may be divided into three classes; 1st, 
small-pox; 2d, the disease termed varioloid, or modified small- 
pox; 3d, an eruption purely vesicular, and presenting all the 
appearances of varicella. 



74 VESICULAR DISEASES. 

A single cause, the variolous contagion, seems to develope 
these various eruptions; they are to be observed in the same 
quarters of the city, in the same streets, and even in the same 
houses. If the disease occurs in a large family, some may 
be affected with small-pox, some with varioloid, and others 
with varicella. One fact was very striking, which was the 
mildness of the disease in vaccinated persons, and in the ma- 
jority of those who had been affected with small-pox, the 
eruption in these individuals offered all the characters of va- 
rioloid, a name given to it from its great resemblance to vari- 
ola, and Mr. Thomson had little difficulty in proving that it 
was only the small-pox, modified by the influence that vacci- 
nation or previous variolation had exerted on the constitution. 

But this gentleman goes farther, and states that the vari- 
cella itself is only modified small-pox, on the following 
grounds: — 

1st. Because, on the one hand, persons placed in contact 
with others actually affected with varicella, had contracted the 
small-pox; and on the other, that the contagion of this latter 
had occasioned small-pox. 

2d. That an epidemic of small-pox never exists without 
varicella, and vice versa. 

3d. And finally, that varicella never developes itself, ex- 
cept in persons whose constitution had been modified by the 
former existence of vaccination or of small-pox. 

These opinions of Mr. Thomson are far from being gene- 
rally adopted. They have even been disputed by physicians, 
who otherwise fully agree with him as to the variolous nature 
the pustular eruptions observed during epidemic small-pox, 
and designated under the name of varioloid. 

In reply to the arguments advanced by Mr. Thomson, in 
support of his opinion, they observe: — 

1st. That during an epidemic small-pox, it is extremely 
difficult to ascertain if the development of this disease in per- 
sons placed in contact with others labouring under varicella, is 
the result of this communication, or of the variolous contagion 
which is causing the disease on every side. 



VARICELLA. 75 

2d. That the true vesicular varicella is not communicable 
by inoculation, and never causes small-pox. 

3d. That those persons who have regarded the varicella as 
contagious, have confounded this disease with the varioloid or 
modified small-pox. 

4th. That varicella appears in unvaccinated persons, who 
have never had the small-pox, and consequently could not be 
regarded as that disease modified by previous variolation or 
vaccination. 

5th. That vaccination, practised a short time after the dis- 
appearance of the varicella, pursues a regular course, which 
never takes place after small-pox. 

6th. That the progress of varicella is always the same, 
whether it appears before or after vaccination or variolation. 

7th. That the small-pox often reigns epidemically without 
being accompanied by varicella, and that on the other hand, 
this latter affection may rage epidemically without being ac- 
companied by the former. 

Finally, that the characters of the eruption and symptoms 
of varicella differ essentially from those of small-pox. 

These objections have been met by Mr. Thomson, but the 
question still remains undecided; hence it appears indispensa- 
ble for us to pursue the route already traced out, and to describe 
varicella among the vesicular diseases, and as a distinct affection. 

Varicella, as we have already said, is a disease characterized 
by an eruption of an indefinite number of vesicles, of a cer- 
tain size, and which dry away, in from five to ten days. At first 
transparent, these vesicles afterwards become opaque. Their 
appearance is preceded or accompanied by general symptoms; 
they are distinct, and often invade the whole body, but by 
successive eruptions. 

Two varieties of varicella may be distinguished; in one, 
the vesicles are small, but little elevated, and contain a limpid 
and colourless fluid; in the other, they are large, globular, 
and soft, being of a greater size at top than at base. At first, 
transparent, the contained fluid soon becomes turbid and as- 
sumes a milky appearance. 



76 VESICULAR DISEASES. 

To these varieties, the English writers have given the name 
of chicken-pox and swine-pox. Both may exist in the same 
individual at different times, and present the same symptoms, 
whether they occur before or after small-pox or vaccination. 
Varicella often reigns conjointly with epidemic small-pox. 
According to some authors, epidemics of varicella alone, have 
been observed. It generally appears in the beginning of the 
year or in the spring. In most cases an individual is but once 
affected, although it may attack several times. It usually takes 
place in young persons, but adults are liable to it. 

Varicella is preceded for twenty-four, thirty-six, or forty- 
eight hours, by depression, general uneasiness, thirst, loss of 
appetite, and constipation. There is often nausea, sometimes 
vomiting, and pain at the epigastrium; the skin is hot, the face 
injected, the pulse accelerated, and there is a tendency to 
sweat. These symptoms may exist in various degrees. In ge- 
neral they do not cease with the appearance of the eruption, 
but continue for two or three days. The eruption usually com- 
mences on the body, but sometimes on the face, and continues 
to make its appearance for several days in succession. 

In the varicella with small vesicles, (chicken-pox,) small 
red elevations, which are irregularly circular, and having in 
their centre a small, transparent vesicle, make their appear- 
ance on the first day. These vesicles augment in size for two 
or three days, some are acuminated, whilst others are flat. On 
the second or third day, the fluid they contain, from being 
transparent becomes milky, the patient experiences great itch- 
ing, and the vesicles become soft and appear diminished. The 
fourth day a red areola surrounds some of them. Towards the 
fifth, desiccation commences, and on the sixth they are re- 
placed by small brownish scales. These small, thin crusts, dry 
from the circumference to the centre, and fall off on the ninth 
or tenth day. As successive eruptions take place for two or 
three days, the different stages of the eruption may be observ- 
ed at the same time, and the duration of the disease is prolong- 
ed to the eleventh or twelfth day. 

Varicella with globular vesicles, (swine-pox,) is preceded 



VARICELLA. 77 

by the same symptoms, and is developed in the same manner. 
The red points are speedily replaced by large vesicles, con- 
taining a transparent fluid, which becomes turbid on the se- 
cond day of the eruption- The vesicles having now acquired 
their full size, are soft and flaccid to the touch, of a pearly 
white colour, and their circumference is larger than their base, 
which is surrounded by an inflammatory areola. 

On the third day the vesicles diminish and become wrinkled, 
whilst the fluid thickens, and assumes a yellowish tint. 

As there exists at the same time great itching, it often hap- 
pens that children open the vesicles in scratching, thus caus- 
ing an increase of inflammation of the part, and the formation 
of a yellowish pus. This happens more particularly on the 
face. The scabs that replace these pustules continue for a long 
time, and leave small cicatrices. The same peculiarity may 
take place in the first variety. 

The vesicles, after having shrivelled, open about the fourth 
day, and are replaced by small, lamellar, brown crusts. These 
scabs dry from their circumference towards their centre, and 
fall off in from four to five days, leaving small red spots, which 
gradually disappear. As the vesicles appear in a successive 
manner during two or three days, various stages of the erup- 
tion may be observed at the same moment. 

Diagnosis, — It is very easy to distinguish varicella from 
well-defined, distinct small-pox, by the regular progress, and 
gradual development of the variolous pustules, which contain 
i thick, white, curdy matter, preceding the appearance of 
the suppuration, as has been pointed out long since by Ash- 
Durner, an English physician. But it is not easy to distin- 
guish between varicella and modified small-pox. 

In this latter affection the precursory symptoms are gene- 
rally violent, which is never the case in varicella. In modi- 
fied small-pox the eruption is pustular. The pustules are small 
md circular, and generally depressed at their centre. After 
:he falling off of the small, scaly scabs, minute tubercles, which 
slowly disappear, are frequently seen. In varicella, the vesicles, 
ilthough at first transparent, now contain a sero-purulent fluid, 

11 



73 VESICULAR DISEASES. 

and are never succeeded by small tubercles, as is the modified 
small-pox. We would also add, that the varicella is not contagious, 
whilst the modified small-pox may be transmitted by inocula- 
tion, and in some instances occasion severe cases of small-pox. 
The treatment of varicella is very simple, a moderated tem- 
perature, tepid drinks, diet, and confinement to bed, are the 
only remedies this disease requires, even in severe cases. 

Eczema. 

The word eczema is derived from the Greek, c -xK i0 h e ff er ~ 
vesco; Willan adopted it to designate one of the genera of vesi- 
cular eruptions. 

La dartre squammeuse humide of Alibert, corresponds 
to one of the stages of eczema; he has also united under this 
denomination the lichen agrius. 

This disease is characterized by vesicles, which are usually 
very small, but conglomerated together in great numbers, and 
often occupying large irregular surfaces. 

Eczema may present wholly different appearances, accord- 
ing to the state in which it exists; this no doubt was the 
cause that Willan divided it into solare, impetiginodes, and 
rubrum. Biett, in his clinical lectures, has, for a long time, 
distinguished it as acute and chronic. This method we have 
adopted. 

In acute eczema, we arrange, 1st. Eczema simplex, which 
constitutes a very distinct variety from its slow progress, but 
is different from chronic eczema. 2d. Eczema rubrum; and 
3d, Eczema impetiginodes. 

1st. Eczema simplex. — This variety presents itself in the 
form of extremely small vesicles, closely distributed, and ap- 
pearing without the slightest inflammatory areola, on a sur- 
face not differing in colour from the surrounding skin. 

It appears without any premonitory symptoms, the pa- 
tient experiences a slight itching, and is astonished to dis- 
cover an eruption on the place. The vesicles that consti- 
tute it are in great numbers, closely conglomerated, small, 



ECZEMA. 79 

transparent, indolent, and presenting a shining aspect; the 
small drop of fluid they contain becomes turbid, and assumes 
a milky appearance; in a short time the fluid is re-absorbed, 
the vesicle shrivels, and falls off by an insensible desquama- 
tion, or opens and forms a small squamous disk, which is ex- 
tremely thin, and soon detaches itself. In no case does the 
eruption give rise to inflamed surfaces, the secretion of fluid, 
or renewal of desquamation observable in other varieties; it 
ioes not leave the slightest mark. 

These different stages take place slowly, and the disease is 
prolonged by successive eruptions; hence its duration, which 
jsually varies from one to three weeks, may be much length- 
ened. 

Eczema simplex may be general, but it is ordinarily con- 
lined to certain spots. It occurs on the arms, between the 
fingers, and sometimes may be mistaken for the itch. It is 
iccompanied by no other symptom than itching, which is 
sometimes very great, particularly if the eruption should be 
general. 

This variety of eczema most frequently occurs in young 
persons, and especially in females. It often arises from fric- 
;ions or irritating lotions. This is the eruption usually occa- 
sioned by the quack remedies to bring out the itch. We have 
several times observed it in persons obliged to remain for a 
length of time near a furnace or large fire. It also arises from 
causes which are scarcely appreciable; thus, it often appears 
between the fingers of women in childbed. 

Eczema simplex is a slight disease, and never accompanied 
jy general symptoms; it is often complicated with itch, being 
lsually produced by remedies employed to cure that disease; 
t also exists with lichen. 

2d. But eczema presents itself in a majority of cases with 
greater severity, and may be divided into two distinct de- 
crees. 

1st. Eczema rubrum. — Here the eruption is usually pre- 
ceded, and always accompanied by well-marked symptoms 
u>f heat and stiffness; the skin is inflamed, and presents a vivid 



80 VESICULAR DISEASES. 

red colour; if it be closely examined, it will be seen that it is 
studded with small elevated points of a silvery hue. At a 
later period, true vesicles may be distinguished, which soon 
acquiring their full size, appear about the size and shape of the 
head of a small pin; they are transparent and surrounded by a 
distinct inflammatory areola. 

From the sixth to the eighth day, sometimes before, the 
redness diminishes; the fluid is re-absorbed, the vesicles are 
shrivelled, and the disease terminates by a slight exfoliation 
produced by the remains of the vesicles. In examining the 
eruption at this time, it still presents marked characters; there 
is a reddish coloured surface, (which remains for some days 
after the cure,) sprinkled with small rounded points, surround- 
ed by a whitish border, irregularly scalloped, which indicates 
the line of demarcation between the elevation of the cuticle, 
that formed the vesicle and the areola surrounding its base. 

Sometimes eczema rubrum does not terminate in so simple 
a manner; the inflammation instead of diminishing, continues, 
or even augments; the vesicles become confluent, break and 
exude the fluid they contained, which, from being transparent, 
has acquired a milky colour. This fluid, flowing over an in- 
flamed surface, irritates it still more, and occasions superficial 
excoriations, and a greater or less weeping of serum. When 
this exudation diminishes, it thickens, concretes, and forms 
soft, thin scales, often of a large size, which are frequently 
renewed, and leave inflamed surfaces on their falling off. The 
serous exhalation gradually ceases, the scales become drier and 
more adherent, and are not detached. The skin slowly reco- 
vers its natural state around the diseased surface, and the com- 
plaint gradually disappearing from the circumference towards 
the centre, ceases in from one to three weeks. But often in- 
stead of improving, these symptoms continue for a length of 
time, occasionally becoming more severe, and the eruption 
assumes a chronic state, which is very remarkable; this we 
shall hereafter describe. * 

* The most remarkable variety of eczema rubrum is that which arises 
from the effects of mercury. Although most authors describe it as being 



ECZEMA. 81 

2d. Whether the vesicles were observable from the com- 
mencement, as is most generally the case, or that the progress 
of inflammation has been so rapid that its products were only 
discoverable at a more advanced stage; it often happens that 
eczema presents an appearance which allies it both to the ve- 
sicular and pustular affections. (Eczema impetiginodes. ) 

In eczema impetiginodes, the inflammation is violent* the 
skin at the inflamed spots is tumefied, the fluid contained in 
the vesicles has lost its transparency, and become sero-puru- 
lent. These pustular, congregated, confluent vesicles, soon 
break; the fluid rapidly thickens and concretes, giving rise not 
to laminae, as in eczema rubrum, but to yellowish, soft scales, 
formed of different layers, and sometimes of a very large size. 
These fall off and lay bare surfaces of a crimson red colour, which 
soon exude a reddish serosity, which follows the same course 
till the inflammation subsides; the pustular vesicles are less 
frequently and generally formed; the scales become thinner, 
and leave spots of a lighter colour on their disengagement, 
till finally the skin regains its natural condition. This erup- 
tion may last two or three weeks, and be confined to a sin- 
gle spot; but sometimes it is general, and in such case is dan- 
gerous, as it is accompanied with general symptoms; the pulse 
is frequent, there is thirst, loss of appetite, &c. 

In most cases, different degrees of inflammation are per- 
ceptible, particularly if the eruption be general or extensive. 
The vesicles may be observed at first transparent, then pass- 
ing into a pustular state, and we have seen some, in which one- 
half was of a milky colour, and not yet become pustular; 
whilst the other, by its yellowish hue and thickened state, in- 
dicated that condition. In those cases of eczema impetigi- 
nodes, which are confined to a single spot, vesicles of eczema 
rubrum are visible, not only around, but even arising among 
the vesicular pustules of the former. This disease, instead of ter- 

confined to a small space, this is not always the case; we have seen a person 
almost covered with the eruption — in this instance the greatest benefit was 
derived from scalded bran. — Tbans. 



82 VESICULAR DISEASES. 

minating in twenty or thirty days, may also become chronic; 
but in such case, it does not differ from the chronic state, suc- 
ceeding eczema rubrum ; at this epoch, nothing but true vesicles 
occur, the pustules having disappeared. 

Eczema impetiginodes therefore is not eczema rubrum, 
complicated with pustules of impetigo, but an eruption, whose 
vesicles, at first transparent, become not true pustules, but pus- 
tular vesicles. Otherwise the disease would be a true impetigo, 
for we perceive that at a certain period, almost all the vesicles 
become pustular, yet nevertheless we shall see in speaking of 
the diagnosis, that marked differences exist between the two 
eruptions. 

The inflammation is sometimes so active that eczema, (and 
this often happens,) may be combined with true pustules of 
impetigo, or even with the larger ones of ecthyma. But these 
elevations of the cuticle contain pus almost from the moment 
of their formation; their base is generally larger, and the fluid 
yellower, and above all, thicker. 

Acute eczema is seldom accompanied with general symptoms 
of a serious character, from oftentimes occupying a large part of 
the body, it would appear to be a dangerous disease, and yet it 
follows a regular march, and soon terminates without having 
occasioned any other symptom than a little elevation of the 
pulse. * 

Chronic eczema. — Whatever may have been the primary 
symptoms, eczema often runs into a chronic state. The skin, 
perpetually irritated by the effusion of an ichorous fluid, and 
by the successive eruptions of vesicles, instead of regaining its 
natural condition, is deeply inflamed; excoriations take place 
and fissures occur, particularly at the articulations, and a con- 
tinual and abundant secretion of fluid renders it necessary to 
change the linen constantly, as it becomes speedily embued 
with the discharge; in doing this, great care must be observed 
not to remove it roughly and thus tear off the scabs, as this is 

* Grocers are said to be liable to this form of eczema, from handling- raw- 
sugars; it also occurs in bricklayers, from the stimulus of the lime. 
Traits. 



ECZEMA. 83 

often followed by a considerable flow of blood, and they leave 
red, sweiflH, flaccid surfaces exposed. The eruption may last 
for several months without the secretion of this fluid diminish- 
ing in any great degree. 

At other times, after a certain time, the fluid is thrown out 
in less quantities, it thickens and forms layers of small, thin, 
soft, yellowish scales, having little adherence, leaving exposed 
on their separation an inflamed but dryish surface. These 
layers form at greater intervals, they become drier, and the 
disease seems on the point of disappearing, when, on a sud- 
den, and without any assignable cause, the inflammation ac- 
quires greater intensity. The diseased spots again become red, 
and covered with vesicles, which soon discharge, and the af- 
fection goes through the same course. The disease may thus 
last for years, having these exacerbations more or less fre- 
quently. 

In some cases there is not the slightest effusion or exhala- 
tion, the crusts become drier, more adherent, but less yellow, 
the skin is thickened and splits, presenting deep fissures. The 
scabs, which are detached with ease, expose a surface but lit- 
tle inflamed. Sometimes, however, and above all, where chro- 
nic eczema is general, the skin remains, even for several 
months, of a vivid red, and covered here and there with thin, 
dry scales, it is also cracked, and there is no appreciable exuda- 
tion of serum. In this state, eczema resembles and may be 
mistaken for certain scaly affections, (psoriasis,) particularly 
as the scales are not produced by the concretion of an effused 
fluid, but appear to be, (as in the scaly eruptions,) laminae of 
altered cuticle. The appearance of vesicles, however, will de- 
signate the true nature of the disease. We saw, in Mr. Biett's 
wards, several examples of eczema, which had thus become 
scaly affections. The vesicular appearance became more and 
more apparent as the patients recovered. 

In some cases there is observed, particularly on the legs, 
that one or more small spots remain, around which the skin is 
smooth, tender, and shining, its surface is covered with whitish 
scales, extremely thin, as if cuticular, no vesicle is perceptible 



84 VESICULAR DISEASES. 

on these shining spots, and the diagnosis would become ex- 
tremely difficult, if a new eruption, or sometimes s%iall vesi- 
cles dispersed around its circumference, did not explain the 
nature of the disease. 

Chronic eczema, at first confined to a small space, may ex- 
tend itself over large surfaces, and, in some rare cases, this 
eruption has been observed commencing about the size of a 
dollar and extending by degrees till it covered a whole limb. 

All these varieties of chronic eczema are constantly attend- 
ed with the most intolerable itching, oftentimes more difficult 
to bear than violent pain. In vain does the patient strengthen 
himself by reason and fortitude, he cannot resist an imperious 
desire to scratch, thus augmenting the evil, which often re- 
turns with agonizing violence. 

This itching is particularly distressing, and throws patients 
into agonies truly worthy of commiseration, when the disease 
is fixed in certain parts, thus when it has its seat on the inter- 
nal and superior part of the thighs, (often induced in women by 
a chronic discharge,) it extends to the anus and vulva, and in- 
duces a pruritus, which sometimes attacks the vagina, and is a 
horrible torment to the sufferer. 

After some time the itching abates, the serous exhalation 
gradually diminishes, and shortly afterwards ceases, the scales 
become drier, and the skin less inflamed. The surface which 
is the seat of the eruption contracts in size, healing first at its 
circumference; the laminae become thinner and smaller, and 
soon disappear; the skin remains somewhat redder than in a 
natural state, but this colour also rapidly vanishes. At last, 
the disease is reduced to an extremely small, dry, red spot, 
covered with very thin scales. The surrounding skin is 
smooth, tense, and even, and recovers its original character but 
slowly; the redness, as we have already said, remains for a 
certain time after the disappearance of the eruption. The du- 
ration of chronic eczema is indefinite, it may continue for 
months or even years. 

Seat. — There is no part of the exterior of the body that is 
not liable to eczema, but there are certain portions very sub- 



ECZEMA. SS 

ject to it, as those which are furnished with hair, or where the 
follicles are numerous, as the pubis, arm-pits, groin, scrotum, 
&c. It may be confined to a single spot, as the breast, scro- 
tum, scalp, or ears, and constitute some important local varie- 
ties. 

It usually attacks several parts simultaneously, and we have 
seen it occupy the whole skin, both in a chronic and acute 
form. 

Causes. — Eczema is not contagious, but under some exceed- 
ingly rare circumstances, it may be transmitted from one in- 
dividual to another, by a prolonged contact of two mucous sur- 
faces. M. Biett has mentioned in his clinical lectures several 
instances of eczema transmitted in coition. It often attacks 
adults, and women appear more susceptible of it than men, it 
occurs the most frequently in the spring or summer. The 
return of the seasons is in general the period when exacerba- 
tions of chronic eczema occur; sudden changes of temperature 
also induce them. It is often developed without any known 
:ause, but is sometimes induced by an appreciable agent, thus 
it may be brought on by the action of a hot lire, the rays of 
the sun, (E. solare, Will.) and is frequently observed after 
;he application of a blister. 

It is also produced by dry frictions, and especially by those 
nade with irritating ointments, it is thus that eczema mercu- 
nale is caused. This does not differ from the other varieties, 
either in symptoms or course. In persons who work in sugar 
^efineries, eczema is often induced by a burn; it is also occa- 
sioned by excess, particularly in spirituous liquors. 

Whatever may be the influence of direct causes in the de- 
velopment of acute eczema, it appears to us, that its passing 
nto the chronic state, and the length of time it remains in 
;hat form, must be attributed to some peculiar predisposition 
)f the system. 

Certain local varieties are produced and kept up by causes 
icting specially on the parts they occupy. Thus a chronic 
eucorrhcea will continue an eczema for an indefinite time. 
Working among the metals, contact with pulverulent sub- 

12 



86 VESICULAR DISEASES. 

stances, with sugar, &c. are all common causes of eczema of 
the hands. 

Diagnosis, — Eczema in all its stages may be confounded 
with wholly dissimilar diseases, hence its diagnosis is of the 
highest importance. 

Eczema simplex is often mistaken for itch, with which, at the 
first glance, it certainly appears to have some analogy; like it, 
it is developed without inflammation; both affect certain spots, 
as the wrist and sides of the fingers; both excite violent itch- 
ing; but the vesicles of eczema are flat, whilst in itch they are 
acuminated; those of eczema are always conglomerated; in 
itch they are usually single and distinct, so that a few only 
are to be met with on a considerable extent of surface, which 
is never the case in eczema. The pruritus in this latter dis- 
ease is a kind of smarting, very different from the exacerba- 
tions in itch; in the first case it is a real pain, while in the se- 
cond it is rather an agreeable than a painful sensation; finally, 
the itch is essentially contagious, whilst the eczema is rare- 
ly so. 

Eczema rubrum presents characters which may cause it to 
be confounded with miliaria, but in the latter the vesicles are 
never confluent as in the former, where in a very small space 
an immense number may be perceived. These are larger in 
miliaria than in eczema. Besides, the general symptoms which 
accompany symptomatic miliaria, are always those of a seri- 
ous disease, and will suffice to distinguish that affection from 
the one under consideration. That variety of miliaria which 
appears in persons who take much exercise during the heat of 
summer, much resembles eczema; but the vesicles are more 
scattered, there exists a greater or less degree of perspiration, 
and the disease rapidly disappears. 

Eczema impetiginodes differs from impetigo in many im- 
portant particulars; the vesicular affection always occupies 
large spaces, whilst the impetigo, on the contrary, is usually 
confined to a small spot. The pustules of impetigo do not con- 
tain a transparent fluid on their first appearance; they have a 
larger base and the fluid is much thicker. The pustular vesi- 



ECZEMA. M7 

eles of eczema impetiginodes are always vesicular at first, 
never contain true pus, but a yellowish serum, or a sero-pu- 
rulent fluid. Besides, what proves still more the difference 
that exists between these vesicles and the pustules of impeti- 
go, is the nature of their products. In impetigo the pustules 
constantly give rise to real scabs, which are always thick, of 
a yellowish colour, rugose and unequal, whilst the pustular 
vesicles of eczema form thin scales, broader than thick; and 
moreover, in this latter disease there are always vesicles of ec- 
zema rubrum surrounding the vesicles, which is never the 
case in impetigo. 

It is very likely that eczema impetiginodes will be con- 
founded with scabies, when the vesicles of the latter affection 
are accompanied with pustules; but leaving these out of the 
question, thy are in almost all cases but a complication with 
another disease, and paying attention to the vesicles alone, 
which are always very numerous, the same rule in their diag- 
nosis is applicable as has been already laid down when* speak- 
ing of eczema simplex. 

Chronic eczema often presents greater difficulties in its di- 
agnosis. Among the eruptions with which it may be con- 
founded, may be cited lichen. This latter affection presents 
two states that are liable to be mistaken for eczema. 

In the lichen agrius there is also an exudation of fluid, 
forming scales, but these scales are smaller, more yellow, and 
thicker than those of eczema, and approach to the nature of 
crusts; they expose, on their fall, not a smooth red surface, 
usually shining and slightly excoriated, as in eczema, but 
one that is studded with small prominent points, (papulae,) 
generally perceptible to the sight, and always to the touch. 

At other times, as happens in chronic eczema, the lichen 
presents thin, dry scales, without any perceptible exudation, or 
local inflammation, but then the skin is much thicker and more 
rugose, so much so, indeed, that it is often difficult to raise a 
fold of it. Besides, in lichen, some papulae, easily distinguish- 
able from their hardness and chronic course, are always to be 
found around the eruption, whilst eczema in most cases pre- 



88 VESICULAR DISEASES. 

sents vesicles in the vicinity of its eruption, which may rea- 
dily be distinguished from the constituents of lichen. 

But when these varieties of either lichen or eczema occur 
on the hands, great attention is necessary to discriminate be- 
tween them. 

Certain varieties of chronic eczema resemble psoriasis; but 
eczema may be distinguished by the presence of vesicles in 
the vicinity of the eruption, or by their consecutive develop- 
ment, added to which the scales are always less dry and fria- 
ble. After their separation, the skin does not present as in 
psoriasis, a red, smooth, and elevated surface, but is chapped 
and fissured. 

Nevertheless, in certain cases of chronic eczema, (very rare 
it is true,) the eruption may be universal, and the skin offer a 
red colour, and at the same time be covered with whitish 
scales; here the diagnosis is the more difficult, if the first ap- 
pearances of the disease have not been noted, and there should 
exist no exudation. This state of eczema may be distinguish- 
ed from psoriasis by the skin not presenting any elevation or 
hypertrophy, as in the latter disease; and by the fissures being 
occasioned by the action of the muscles, and not covering the 
surface of the skin in all directions, as in psoriasis inveterata. 
But, we repeat, that much discrimination is requisite in these 
cases, and we are sometimes obliged to wait for a renewed ex- 
acerbation of the disease to dissipate all doubt. 

Prognosis. — Eczema is ordinarily a slight disorder, parti- 
cularly when it exists in an acute form, but when it becomes 
chronic, and at the same time is of some extent, it constitutes 
a very troublesome disease. The prognosis is worse when it 
has lasted for some years, and fresh eruptions appear at the mo- 
ment it appears ready to terminate. Without endangering the 
life of patients, it embitters their existence, when it thus re- 
mains for an indefinite time. It may occur with lichen, and 
above all, with scabies. It is also often complicated with pus- 
tules of impetigo and ecthyma. 

Treatment. — In eczema simplex it is sufficient in a majo- 
rity of cases to keep the patient on the use of acidulated 



ECZEMA. 89 

drinks, and occasional tepid baths; these will remove the dis- 
ease in a short time, but if it continues, and is accompanied 
with great itching, or the eruption is extensive, laxative drinks 
should be prescribed as well as alkaline or sulphurous baths; 
the alkaline baths are made by adding four to eight ounces of 
subcarbonate of potash or soda to a bath, according to the age 
of the patient or state of the eruption, and four ounces of sul- 
phuret of potash for a sulphurous bath. Frictions, with the 
sulphuro-alkaline ointment, should also be employed, if the 
disease should last for any time. 

Eczema rubrum and impetiginodes require the same 
treatment as acute inflammations, viz. diluent drinks, and a 
strict diet, when they are local and of little extent. But if they 
occupy a large surface, and are accompanied with excitement 
in the pulse, particularly if the patient be young and, vigorous, 
it is necessary to recur to blood-letting, either general, or lo- 
cal, by leeches in the vicinity of the eruption; sometimes- 
both modes are requisite. If the disease is very extensive, 
these should be repeated. 

Diet, simple or emollient baths, or local bathing with a de- 
coction of bran, or mallows, &c. and cataplasms made of po r 
tatoes and an emollient decoction, when they break and leave a 
red and excoriated surface, are the only remedies required for 
acute eczema. The sulphurous preparations, so indiscrimi- 
nately used in the cure of all the scabby eruptions, should be 
sedulously avoided. The same may be said of mercurial 
treatment; we have seen patients enter the Hospital St. Louis, 
in whom the eczema rubrum kept up and exasperated by these 
modes of practice, had passed into eczema impetiginodes, and 
was often attended with pustules, either of impetigo or ecthy- 
ma, lasting for months; and on the otherhand, we haveobserved 
acute cases, occupying the whole surface of the body, and ap- 
pearing to constitute a serious disease, yield in twelve or fif- 
teen days to a well-regulated antiphlogistic treatment. In all 
cases, the first thing is to remove the exciting cause; thus fric- 
tions must be put a stop to, or the patient taken from his ha- 
bitual employment, if these should be the origin of the com- 



90 VESICULAR DISEASES. 

plaint. We have several times seen, and among others, in 
a man employed in an apothecary's shop, the eczema sim- 
plex invariably return on his resuming his usual employ- 
ment. 

Chronic eczema, when it has not acquired that height which 
renders it a troublesome and serious disease, generally yields 
to the following remedies: — 

Acidulated drinks and baths are to be freely employed. A 
half to one drachm of sulphuric or nitric acid to a pint of 
water is to be given — the nitric is more powerful than the 
sulphuric acid; these suit all those cases where there is an 
abundant exudation of fluid, accompanied with violent itching. 
The patient should take it in small quantities at a time, or even 
drink fresh water afterwards for the first few days, till the 
stomach becomes accustomed to its use. 

The temperature of the baths should be from 25° to 27° of 
Reaumur, (88° to 92° Fahr. ) and the patient remain in them 
for about an hour; they may be rendered emollient by the 
addition of mucilage or gelatine. The quantity of gelatine 
necessary for a bath is from a half to one pound. 

Sometimes recourse must be had to laxatives; they may be 
employed alone or alternately with the acidulated drinks. Thus, 
veal water, or an infusion of chicory may be given, with the 
addition of half an ounce of sulphate of soda to the pint, or the 
same quantity of sulphate of potash; these may be augmented 
or diminished, according to circumstances. Whey, with the 
addition of two drachms of cremor tartar will fulfil the same 
indication. Alkaline remedies may be employed with much 
advantage, both internally and externally. They are used in 
the latter way, when in despite of the use of emollients, the 
itching is very violent. Then local baths, with the addition 
of one or two ounces of subcarbonate of potash or soda, will 
afford great relief; the patient should make use of them before 
he retires to bed. Half a drachm to a drachm of the subcar- 
bonate of potash in a pint of infusion of chicory may be given 
internally. 

When the eruption is of long standing, and occupies a large 



ECZEMA. 91 

surface, more active means must be resorted to, as purgatives, 
sulphurous waters, vapour baths, and douches. 

Calomel may be administered in doses of four to six grains 
or several weeks, or one or two of Plumber's pills, or those 
)f aloes, jalap, or gamboge, in purgative doses, always regu- 
ating their employment by the state of the digestive organs. 
>eidlitz water is also useful ; the patient should drink one or 
wo glasses every morning. Sulphurous waters may be used 
nther internally or to the surface; they are peculiarly suited 
o old cases, particularly where the eruption is fixed in the 
ower extremities, and presents a violet colour. Bareges, 
1'Enghein, and Cauteretz waters, are the most used, they may 
)e artificially made, by adding to each bath two to three 
)unces of sulphuret of potash, varying the quantity according 
to the effect to be produced. In all cases, it is proper to use 
simple baths alternately with the medicated. When sulphur- 
>us waters are given internally, it is better to dilute them at 
irst with two-thirds of barley water or milk, and gradually 
mgment the quantity until the patient can take them alone. 

Local or general baths, either simple, or rendered emollient, 
ire, as we have already observed, the best suited to the com- 
mencement, or where the inflammation becomes more vio- 
lent. In these cases, whatever may be the remedies employed^ 
it is also advantageous to apply leeches to the vicinity of the 
sruption. 

Vapour baths are sometimes very useful in cases of chronic 
eczema, but the patient should not be exposed to too great a 
degree of heat, nor approach the spot from whence the vapour 
issues. Douches of vapour are often of great utility when the 
disease is local. 

When the eruption is confined, or reduced to a small spot, the 
cure is sometimes hastened by slight frictions with an ointment 
of the ammoniacal proto-chloruret of mercury, of the strength 
of ^i. to 3ss. to the ^i. of axunge. In the course of the treat- 
ment, lotions of lead water, or of emulsion of bitter almonds, 
or even of a decoction of some of the poisonous plants, as dul- 
camara, hyosciamus, &c. should be often employed to allay the 
violent itching. 



92 VESICULAR DISEASES. 

In certain cases, the chronic eczema resists all these means, 
and it becomes necessary to employ more powerful agents, if 
there does not exist any chronic affection of the digestive or- 
gans. In these cases of obstinate eruption, we have seen the 
following preparations succeed in an astonishing manner. 1st 
Tincture of cantharides, especially in women. 2d. Some ot 
the arsenical preparations, by the aid of which M. Biett has 
promptly cured many cases of severe and inveterate eczema 

The tincture of cantharides is given at first, in doses of 
three, then five drops, every morning in a little drink, and 
every six or eight days the dose augmented five drops. It 
may be thus carried as far as twenty-five to thirty drops at a 

dose. . , ,, 

Among the arsenical preparations, those which succeed the 
best, are the Asiatic pills, of which one is to be taken a day, 
and their use continued for a month or six weeks. 

The administration of these remedies demands much atten- 
tion on the part of the physician; their use must be suspended 
when any signs of irritation manifest themselves, but the un- 
easiness the patient experiences on first using them, must not 
be mistaken for irritation, this soon disappears. However, it 
is often advantageous to relinquish their use for a few days, 
and again to recur to them. 

In those cases where the eczema occupies but a certain 
space, and is of the scaly form, the skin dry, cracked, and a 
little thickened, (as occurs in the hands,) it is often useful to 
employ local remedies, somewhat active. In such instances, 
frictions on the eruption of proto-nitrate of mercury, (S>i. or 
3ss. to axunge, |i.) or proto-ioduret, @i. to axunge, Ji.) or 
deuto-ioduret of mercury, (gr. x. to xii. to axunge, §1.) are 
very advantageous. To allay the itching, camphor, grs. xij. 
may be added to these ointments. These mercurial prepara- 
tions often produce happy results, but the advantages from 
those which have been prescribed internally, are at least doubt- 
ful, if not hurtful. _ . 

In these cases it is particularly beneficial to employ the sul- 
phurous baths, either general or local, but the greatest benefits 
have been experienced from douches of vapour. 



ECZEMA. 93 

Cauterizations should never be employed in the treatment 
of eczema, the use of stimulating ointments is much prefera- 
ble. M. Biett has always regarded their employment as pre- 
judicial. 

Before finishing this subject, we will make a few observa- 
tions on certain cases, where, from having a local seat, they 
present some peculiarities. 

Chronic eczema of the breasts is often confined to a small 
spot; it regularly surrounds the nipple, and gives rise to deep 
fissures. It requires a very active treatment, is generally ob- 
stinate, and sometimes lasts for years. 

Eczema of the scrotum, and that of the thighs in women, 
are always stubborn, as is also that which occupies the vicinity 
of the anus. Douches of vapour, sulphurous fumigations, and 
purgatives, are the means that offer the most advantageous re- 
sults. In robust persons, enjoying good health, purgatives 
may be freely used. 

Eczema of the ear is often very refractory; and, as it is 
sometimes accompanied with hypertrophy and chronic swell- 
ing, it may be necessary to introduce pieces of prepared sponge 
in the auditory canal, to prevent the closure of this opening. 

Finally, eczema of the scalp may present itself with va- 
rious symptoms, which sometimes cause it to be mistaken for 
porrigo. Alibert has even described, under the names of 
teigne amiantacee and furfur acee, two diseases, which, for 
a long time, M. Biett has regarded as only varieties of chronic 
eczema of the scalp. 

Thus may we see patients attacked with an eczema which 
often occupies both the face and scalp, but sometimes the latter 
only, with a secretion of fluid so abundant as to saturate the 
hair. At a later period of the disease the fluid thickens, and the 
scales in their formation surround the young hair. These 
scales are soon detached, either by natural exfoliation, or by 
the growth of the hair, but still remain adherent, and firmly 
attached to this substance. This phenomenon is less visible in 
females, but may be observed if the hair be examined near its 
origin. The presence of these scales of a chaytoyant white 

13 



94 VESICULAR DISEASES. 

colour, like that of amianthus, among the hair, has a singular 
effect, particularly where the hair is dark, (teigne amian- 
tacie.J 

Sometimes the serous exudation is less abundant, and this 
liquid in drying occasions small, white, dry, branny scales, 
which are renewed with extreme rapidity, and are disengaged 
in great abundance by the least friction. This variety consti- 
tutes the teigne furfur acie, (porrigo furfur ans, Will.) 
which also appears to have been mistaken in some instances 
for pytiriasis capitis. These forms of eczema do not injure 
the hair. 

Acidulated drinks and emollient lotions at the commence- 
ment, and afterwards alkaline washes and mild laxatives, are 
the only remedies these diseases require. It is sometimes suf- 
ficient in children, to wash the head with soap and water, and 
to pass a fine comb through the hair several times during the 
day. 

It is proper to add, that the appearance of vesicles on the 
forehead, ears, &c. even at an advanced stage of the disease; 
the effusion of a serous fluid and the nature of the scales, are 
characters which will always distinguish these two forms of 
eczema from the different varieties of porrigo, which are pus- 
tular diseases. 

Herpes. 

The genus herpes corresponds to the dartre phlyctenoide 
of Alibert, who describes but two varieties; 1st, Dartre phlyc- 
tenoide confluente, which appears to resemble both herpes | 
phlyctenodes and pemphigus; 2d, Dartre phlyctenoide en 
zone, which is herpes zoster. 

The word herpes, used for a long time in a vague manner, 
and having the same meaning as dartre or tetter, was applied 
to several diseases of wholly different characters, till Willan 
restricted it to a distinct class of eruptions. 

It is characterized by an eruption of vesicles, always as- 
sembled in groups on an inflamed surface, so as to present 



HERPES. 95 

one or more perfectly distinct spots separated from each other 
by intervals of sound skin. 

The form of these groups, and their seat, constitute spe- 
cies and varieties sufficiently distinct to be separately de- 
scribed. 

The various species of herpes usually follow an acute 
march; their duration is generally one week, and is rarely pro- 
longed beyond two or three. 

Cases attended with violent general symptoms are very 
rare, if they exist at all. These, generally consist in a 
slight uneasiness and languor, sometimes loss of appetite, but 
rarely fever. In some uncommon instances herpes is induced 
by direct agents, but in general it is developed without 
any appreciable cause, and even in those cases that arise from 
a direct influence, as a cold wind, (herpes labialis,) there 
exists at the same time a particular state of the constitution, of 
which herpes is one of the symptoms. 

The aggregation of the vesicles in groups, on a circumscribed 
and inflamed base, will always prevent their being confound- 
ed with any other vesicular affections. 

These diseases are always slight, usually follow a regular 
march, and only require a very simple treatment. Herpes 
may however exist, simultaneously with other diseases, either 
of a cutaneous or internal character. 

Herpes phlyctenodes. 

Under this head are included all those varieties of herpes 
that have neither a determined form or seat; the others are 
only separated because they possess one of these characters. 

Herpes phlyctenodes is distinguished by the presence of 
vesicles, generally of a small size, but always aggregated, ma- 
nifesting themselves on all parts of the body, in some cases on 
several of them simultaneously, and forming irregular spots, 
whose size varies from that of a dollar to that of the palm of 
the hand. In the same eruptions, vesicles may be found, some 
of which are imperceptible, whilst others are as large as a pea, 
but the number of the small ones always is the greatest. 



96 VESICULAR DISEASES. 

It generally occurs on the upper parts of the body; the 
cheeks, neck, breast and arms, are its most frequent seats. 

Herpes phlyctenodes is usually confined to one or two 
groups, and disappears about the seventh or eighth day. But 
either from its being developed on different points in succes- 
sion, or from several groups making their appearance contigu- 
ous to each other, it may be retarded, though seldom beyond 
two weeks, and never more than three. 

When this disease manifests itself in several groups, they 
are generally distant from each other, but however contigu- 
ous they may be, the intervening skin is always sound, and 
remains unaltered. 

Symptoms. — Each group is developed in the following 
manner; on the spot which is about to be the seat of the dis- 
ease, a multitude of almost imperceptible red points are to be 
observed, grouped around each other, and whose number is 
often very considerable, although confined to a relatively small 
space. On the next day there may be perceived a red inflamed 
surface, covered with prominent vesicles, hard to the touch, and 
whose size varies from a grain of millet to that of a small pea. 
The redness of each group extends for some lines beyond the 
vesicles. These vesicles, although they may be in great num- 
bers, occupy but a small space. They are all hard, resisting, 
of a globular form, and transparent on the first day of their ap- 
pearance, but on the following day, or even before, the trans- 
parency is followed by a milky tint. 

A feeling of smarting, oftentimes of a severe character, ac- 
companies the appearance of each group. The vesicles com- 
mence shrivelling on the third or fourth day, and on the se- 
venth or eighth are dried up; some, however, contain a puru- 
lent fluid, whilst others are changed into brownish scabs. De- 
squamation soon takes place, but slight ulcerations are some- 
times observable. A red colour, which slowly disappears, al- 
ways remains for some days after the disappearance of the 
eruption. 

In most cases this slight affection is neither preceded nor 
accompanied with general symptoms; a state of general uneasi- 



HERPES. 97 

ness, sometimes loss of appetite, and a little fever are the only 
ones present when the disease is of some extent: the local 
symptoms are, as we have already mentioned, a feeling of 
smarting and of burning. But these symptoms, whether local 
or general, only occur on the appearance of the eruption dur- 
ing the first two or three days. 

Causes. — Herpes phlyctenodes usually takes place in chil- 
dren. Watching, excess in food, grief, and other causes of 
like nature, have often appeared to exercise an influence on its 
development, but in most cases it is produced by unknown 
causes, or by such as are difficult to appreciate. 

Diagnosis. — The characters of herpes phlyctenodes, as al- 
ready given, will serve to distinguish it from other eruptions, 
whether they are vesicular or bullar. Pemphigus is the only 
disease with which it is liable to be confounded, particularly 
as the descriptions of this eruption have been given as herpes 
phlyctenodes. They may be distinguished from each other, 
by the vesicles in herpes being grouped in detached spots, 
whilst in pemphigus the bullae are isolated. Sometimes, it is 
true, these red surfaces are found in the latter disease, where 
the blebs are closely united, and almost confluent, but they 
will not be confounded with herpes, if it be recollected, that 
in this affection, vesicles, not bullae, occur. Some vesicles, it 
is true, may be transformed into bullae, but these are very few 
in number, and very much scattered. As to the other forms 
of herpes, as they only differ in their form and seat, these cir- 
cumstances form a sufficient differential diagnosis. 

Treatment. — Herpes phlyctenodes is a slight disease, and 
in the generality of cases, only requires the use of diluents, 
some attention to diet, and a few warm baths. If the disease 
is of some extent, and there are general symptoms, a small 
bleeding may be prescribed. 

a. Varieties from Situation. 

These varieties only differ from herpes phlyctenodes , from 
their having a particular seat; they are two in number, herpes 
labialis and preputialis. 



98 VESICULAR DISEASES. 



Herpes labialis. 

This variety only differs from herpes phlyctenodes by 
its seat; it is characterized by groups of vesicles occur- 
ring round the mouth. In general, herpes labialis only 
occupies a certain extent of either the upper or lower lip. It 
always appears at the outer angle, and usually at the point of 
junction of the mucous membrane of the lip with the skin. 
Nevertheless, in certain cases, it only attacks the mucous mem- 
brane, and in others the skin near the line of junction. Some- 
times the groups are irregularly placed, and may extend to 
the cheeks, the chin, alae of the nose, and even, in some cases, 
to the pharynx. 

Herpes labialis is sometimes preceded by a slight redness 
for some hours, at others, the eruption appears suddenly. The 
spot where it occurs swells, and becomes hot and burning, 
presenting a red, shining, and tumefied surface, painful to the 
touch, with here and there a few vesicles. The swelling of the 
lip extends beyond the group of vesicles. These last are ra- 
pidly developed, sometimes several are united, attain the 
size of small peas, and are filled with a transparent fluid. The 
heat is in general less violent after the formation of the vesi- 
cles; the transparent fluid they contain soon acquires a milky 
hue, and, on the third or fourth day, presents a yellowish ap- 
pearance, and has become sero-purulent; the redness and swell- 
ing have almost disappeared, crusts soon form, which become 
brownish, and fall off on the seventh or eighth day of the erup- 
tion; if they are picked off too soon they are succeeded by 
others, which remain for a long time. After the disappearance 
of the eruption, a small red spot remains, which soon vanishes. 

Causes. — Herpes labialis is often occasioned by cold ; thus, 
it often occurs from leaving a warm apartment, and suddenly 
being exposed to a cold and moist air. It is frequently accompa- 
nied with coryza, and a slight bronchitis. The contact of cer- 
tain acrid and irritating aliments may cause the appearance of 
this variety of herpes. It often supervenes on intermitting 



HERPES [)9 

lever, and is sometimes complicated with inflammation of some 
interior organ, but particularly those of the thorax. 

Diagnosis. — The disposition of the vesicles in isolated 
groups, their regular course, the large size which some of them 
acquire, and their containing a sero-purulent fluid, will suffice 
to distinguish herpes labialis from eczema of the lips. 

Herpes labialis is usually a very trifling disease, and sel- 
dom requires any treatment. But in the cases where it is ac- 
companied with a burning heat and painful swelling, these 
symptoms may be mitigated by lotions of cold water, to which 
may be added a few drops of sulphate of zinc, acetate of lead, 
or sulphate of copper. Emollients produce but little good, 
but neither treatment will prevent the disease from pursuing 
its regular course. In all cases, exposure to cold, or the heat 
of a strong fire, should be avoided. 

Herpes preputialis. 

Herpes preputialis is also a variety of herpes phlyctenodes, 
from which it only differs in its seat. It is characterized by 
occurring on the prepuce, either externally or internally, in 
the form of groups of vesicles. 

It is first manifested by several red spots, which are more 
or less inflamed, and about the size of a franc piece, but often 
much less. These spots are soon covered with small vesicular 
globules, whose development differs somewhat according to 
their seat. 

Thus the eruption may be confined to the interior or exte- 
rior of the prepuce, or occupy both. The groups which oc- 
cur on the exterior are but little inflamed, the transparent and 
distinct vesicles follow the ordinary course of herpes, except 
that the fluid is generally absorbed, when the vesicles shrivel 
and a slight exfoliation takes place; in some cases, however, 
the fluid becomes turbid in a few days, small scales are form- 
ed, and the disease terminates on the seventh or eighth day 
at latest. 

But in the groups situated on the interior of the prepuce, the 



100 VESICULAR DISEASES- 

inflammation is much greater, the vesicles rapidly augment in 
size, and often are united two and two, three and three. They 
are extremely thin, and their transparency is so great as to 
permit the red colour of the surface they occupy to be seen 
through them. The fluid speedily passes into a sero-purulent 
state, the vesicles break and form small scales, which are soon 
detached either naturally or accidentally, leaving excoriations, 
which may be readily distinguished from syphilitic ulcerations; 
causing no cicatrix on their healing. 

A slight uneasiness at the commencement of the eruption, 
and a little smarting when excoriation takes place, are the only 
symptoms that accompany this disease. 

Causes. — This variety of herpes is only observed in adults; 
chafing of woollen clothing, certain chronic discharges from 
the vagina, the action of the matter which is so abundantly 
secreted between the glans and prepuce, if it is permitted to 
collect, may all occasion this eruption, but which generally 
occurs without any assignable cause. Strictures of the urethra, 
which may exist at the same time, have no other connexion 
with the eruption than their simultaneous appearance. 

Diagnosis. — The seat of this variety may throw some ob- 
scurity on its diagnosis, if a superficial examination only is 
made; but in whatever state it occurs, it appears to us that it 
would be difficult to confound it with syphilitic eruptions or 
ulcerations. Is it vesicular? All the characters of the genus 
herpes are applicable to it, and permit no error. Is it cover- 
ed with scales? No person can take these thin, flat scales, for 
the prominent and thick scabs of syphilitic eruptions. Finally, 
has it left excoriations? These all being superficial and the same 
depth at the centre as at the circumference, disposed in groups, 
like the vesicles which gave rise to them, &c. can never be 
mistaken for syphilitic ulcerations, which are remarkable for 
their depth, for their hard and elevated edges, and by the 
whitish exudation that covers them. 

Treatment. — Lemonade and barley water, injections of a 
decoction of mallows between the prepuce and glans, and 
emollient local baths are all the means necessarv to be used 



HERPES. 101 

for this form, which in general is cured with great facility. 
Nevertheless, in some cases, it may become chronic and resist 
the most energetic treatment M. Biett has seen several ex- 
amples. * 

b. Varieties from For . 

The genus herpes also includes three important varieties, 
which appear to be distinct species, but which, attentively ex- 
amined, only differ from Herpes phlyctenodes by their deter- 
minate form. However, as they constitute diseases of frequent 
occurrence, and as there exists doubt on the nature of some of 
them, it has appeared to us that they should be separately de- 
scribed. These are Herpes zoster, H. circinnatus, and H. 
iris, which latter constitutes an extremely rare variety, rang- 
ed by Willan in the exanthemata, and sometimes really ap- 
proaching a variety of roseola, we have described as roseola 
multi annulata. 

Herpes Zoster. Shingles. Zona. 

This has been regarded and described as a species of erysi- 
pelas, but this error has so little foundation, that it almost suf- 
fices, merely to notice it; in fact, none of the symptoms of that 
eruption are to be found in Herpes zoster, and, above all, no 
symptoms of herpes in erysipelas, we will, however, dwell for 
an instant on the probable cause of this opinion. It is doubt- 
less based on the fact that certain cases of erysipelas are com- 
plicated with bullae, but there exists a great difference between 
isolated, imperfect, and often extensive elevations of the cuti- 
cle, as occur in erysipelas, and the small, aggregated vesicles, 
rarely larger than a pea, which constitute herpes. This rea- 

* The hydro-cyanic acid with alcohol, used as a lotion, has been very ef- 
fectual in removing" obstinate cases of herpes attacking the g-enital organs in 
females, the proportions are a drachm and a half to two drachms of prussic 
acid to six ounces of alcohol. — Hufeland's Journal, October, 1827. 

Mr. Lisfranc has employed lotions of chloride of soda in obstinate cases of 
herpes with great success.™ -Tkans. 

14 



102 VESRILAH DISEASJ - 

son, added to the regular march of Herpes zoster, whichis iden- 
tical to that of H. phlyctenodes. suffices to unite these two af- 
fections, and to distinguish the former from erysipelas. 

In a recent work, the author, no doubt, led away by a desire 
of novelty, wished to correct Willan, but it appears to us that 
he has transplanted this disease to an order to which it is as 
much unallied as to the exanthemata. For what in fact has it 
in common with the bullar eruptions? Nothing, absolutely 
nothing. Nevertheless, because some of the vesicles in a group 
may have acquired a somewhat larger size than usual, a pre- 
text for correction has been found, but it is far from being a 
happy one. 

In all the bullar inflammations, the small aqueous tumours 
are always isolated: in zona the vesicles are uniformly group- 
ed together in great numbers. The bullae in rupia and/?e?/2- 
phigus are generally developed on several parts of the body 
at the same time, and in an irregular manner: zona is always 
confined to a particular seat, and appears in a peculiar form. 
The large size of some of the vesicles in this disease, is only 
accidental, and is found but in a few of the groups, whereas in 
the bullar eruptions, the volume of the aqueous tumours 
is remarkable in all. We do not therefore see why it should 
have been separated from herpes, as it possesses all the cha- 
racters of the genus. We think with Willan, that this is its 
true and only place. 

Herpes zoster is characterized by irregular patches of various 
sizes, and of a vivid red colour, which are covered with con- 
glomerated vesicles, and presents the form of a half belt or 
zone on the body. The zone usually commences at the me- 
dian line of the body, and runs to an opposite point, without 
ever passing this line. 

This eruption is generally met with on the body, where, in 
a majority of cases, it forms an oblique demi-zone. It is not 
rare, however, to see it commence on the body, and finish on 
the limbs. Thus, often beginning on the middle of the in- 
ferior and posterior lumbar region, it obliquely surrounds the 
external and anterior iliac region to arrive at the groin, and 



HERPES. 103 

terminates on the internal part of the thigh, or commencing at 
the upper and middle part of the back, it reaches the posterior 
part of the shoulder, then the anterior, and terminates on the 
internal part of the arm, sometimes running down to the cu- 
bital border of the hand. Some cases are also met with, in 
which two lines arise from the half zone, one extending along 
a lower extremity, whilst the other follows the course of the 
arm. But the most common seat of this affection is the lower 
part of the thorax, it is rarely seen attacking a limb only. 
Nineteen times in twenty, zona is found on the right side of 
the body, without our being able to account for this singular 
predilection. It never exists on both sides at the same time. 

In all cases, these half belts are formed, not by a succession 
of vesicles, but by isolated patches which follow the same 
course, and exhibit intervals where the skin is perfectly sound. 
Sometimes these patches are contiguous, and at others the in- 
tervals between them are considerable. The duration of the 
disease is from three to four weeks. 

Symptoms.* — Zona shows itself at first in irregular patches, 
of a vividred colour and atshortdistancesfrom each other, which 
are successively developed, until half the body is surrounded. 
Sometimes these spots commence at the two extremities of the 
zone at the same time, and become united by successive erup- 
tions. Those which begin and end this kind of chain are usu- 
ally the largest, and present an irregularly rounded form, 
whilst the patches which are included between them, are small. 
In some rare cases the development of these spots is preceded 
by a painful and burning sensation. If they are attentively ex- 
amined, a multitude of small, white, silvery points will be per- 
ceived, which soon augment in size, and assume the form of 
distinct transparent vesicles, of the size and appearance of 
small pearls. They attain their greatest degree of development 
in three or four days, and rarely exceed in size, that of a large 
pea, though in some instances they may acquire considerable 
bulk. At this time the surface on which the vesicles are 
situated, is of a vivid red colour; and this hue extends for some 
lines beyond the edge of each group of vesicles. According as 
fresh groups are developed, they follow the same course. 



104 VESICULAR DISEASES. 

Towards the fourth or fifth day from the appearance of the 
vesicles, the redness diminishes; the vesicles shrivel, and be- 
come wrinkled. The fluid they contain, from being transpa- 
rent, becomes opaque, or even blackish; and even pus is to be 
found in some; finally, small light crusts of a deep brown co- 
lour are formed, w T hich fall off in a few days. Other groups 
follow the same march, and towards the tenth or twelfth day 
small red spots only remain, which gradually disappear. But 
it sometimes happens, and particularly where the disease is 
situated on the posterior part of the thprax, that the vesicles 
are succeeded by excoriations or even slight ulcerations, which 
appear to result from the chafing of the diseased parts against 
the bed; the duration of the disease is thus much prolonged. 

Such is the usual course of zona, but it may present many 
varieties; thus absorption of the fluid may occur towards the 
fifth or sixth day, and the disease terminate by desquamation 
on the seventh or eighth; at other times, in persons enfeebled 
by age or privations, the vesicles acquire a considerable size, 
soon open, and leave large and painful ulcerations, followed 
by well-defined cicatrices. In some very rare cases, particu- 
larly in old persons, zona has been followed by a gangrene of 
that part of the skin on which the vesicles were situated. 

We have observed a great number of instances of zona in 
the Hospital of St. Louis, and have never seen it accompanied 
with those general symptoms, and particularly of a gastric 
nature, with which it has been asserted it is always attended; 
a state of uneasiness, in some rare cases a slight excitement of 
pulse, heat of skin, a sensation of tension, which is generally 
painful about the seat of the eruption, acute pain in those cases 
where the disease terminates in ulceration, and finally, a 
slight local pain remaining some time after the eruption has 
disappeared, (not acute, as has been said,) are the only pheno- 
mena, which, in a majority of cases at least, accompany this 
variety of herpes. If it was necessary to bring additional 
proof to this assertion, we would cite the opinion of M. Biett, 
who has never seen those violent symptoms described by au- 
thors, in more than five hundred cases that he has treated at 
the Hospital of St. Louis. 



HERPES. 105 

Causes. — Herpes zoster most usually attacks young per- 
sons and individuals in whom the skin is fine and delicate; it 
is more often observed in men than women; it sometimes ap- 
pears in the aged, and more usually manifests itself in the sum- 
mer and autumn than in the spring or winter. It is sometimes 
met with after small-pox and may reign epidemically. 

Diagnosis. — This affection cannot be confounded with 
any other; its vesicular nature and peculiar form are two 
symptoms that preclude the possibility of error. Sometimes, 
at the commencement of an attack, or when its development 
is incomplete, a single group only, is perceptible near the me- 
dian line, and may be taken for Herpes phlyctenodes; but 
it often suffices in these cases to examine the opposite part of 
the body, when other groups of vesicles may be detected, ad- 
ded to which, small red points, the indications of new groups 
about to appear, generally exist on the line between these se- 
parated patches; but at all events, the error is of no conse- 
quence, as the two diseases are nearly similar. 

Prognosis, — Zona is seldom a severe disease, but when it 
terminates by ulceration it may be troublesome, and still more 
so when it is followed by gangrene of the skin, which has 
latterly been observed to occur in elderly persons. 

Treatment. — In almost all cases zona disappears under a 
very simple treatment, as a regulated diet, rest, and diluent 
drinks, as lemonade, &c. ; it is seldom requisite to recur to 
either local or general bleeding. A few simple baths are ad- 
vantageous where the inflammation is high and the patients 
restless. Local applications are useless. Those which have 
been the most extolled are saturnine or other astringent lo- 
tions. If ulcerations take place they should be treated with a 
slightly opiated cerate. 

If the disease occurs in an individual who is enfeebled 
either from age or internal disease, tonic drinks, as ferrugin- 
ous waters, may be given with advantage, and at the same 
time the strength of the patient kept up by a nourishing diet. 

When it terminates in gangrene, recourse must be had to 
tonics and stimulating local applications. Is it necessary to 



106 VESICULAR DISEASES. 

speak of the application of the ectrotic treatment in this dis- 
ease? It appears to us, to say the least, that it is useless in a 
malady, which, in the generality of cases, is slight and sim- 
ple.* 

Herpes circinnatus. 

This name has been given to a frequent variety of herpes 
which appears in the form of rings. 

It is characterized by globular vesicles, mostly of a very 
small size, disposed in such a manner as to form complete 
circles, the centre of which is generally in a healthy condi- 
tion, and the edges, which are of different shades of red, are 
covered with small vesicles. This red band is often very large 
in comparison to its centre, particularly when the rings are 
small ; the red colour extends beyond the vesicles on both cir- 
cumferences. 

Symptoms. — This eruption commences with a certain de- 
gree of redness of the spot, on which the vesicles are to appear. 
This redness, sometimes confined to a surface whose extent 
does not exceed that of a shilling, may in some cases be two 
inches in diameter. Though generally, perfectly round, it 
sometimes presents an oval form. In small spots the redness 
is slighter in the centre, and in large ones the skin preserves 
its natural colour. In all cases, the circumference of the circle 
soon becomes covered with extremely small vesicles, closely 
set together, which when examined with attention, appear of 
a globular form. Although at first transparent, the fluid con- 
tained in these vesicles soon becomes turbid, the vesicles 
break and are succeeded by small scales which are usually 
very thin, and soon fall off, and in a majority of cases the erup- 
tion runs its course in eight or ten days, leaving only a red- 
ness which slowly disappears. 

* Bateman says that this disease cannot be shortened by medicine. But 
from more recent experience, this is found to be an erroneous opinion, as 
the complaint will certainly in some cases at least yield to local treatment. 
Mr. Geoffroy has found beneficial results from lunar caustic. See Rev. Med 
Jp. 1826.— Triws. 






HERPES. 107 

Such are the most usual stages of this disease, but in some 
instances the centre of the ring is also inflamed, and a slight 
desquamation occurs without vesicles being formed. Some- 
times the vesicles do not terminate by the formation of scales, 
but the fluid is absorbed, the vesicles shrivel and are detach- 
ed by an almost insensible exfoliation. This usually takes 
place in the small rings, and in such cases the vesicles are so 
extremely minute as to require close observation to detect 
them. Finally, in some cases the circles are very large, and 
the vesicles attain the size of a grain of millet. 

Herpes circinnatus generally lasts from eight to ten days, 
when there is only one ring, or when they are few in num- 
ber and are developed simultaneously. But where the rings 
appear successively, the duration of the disease may be pro- 
longed for two or three weeks. In persons with a delicate 
skin the redness often remains for a length of time after the 
disappearance of the eruption and scales. 

Although this disease may occur on all parts of the body, 
it generally selects the arms, shoulders, or breast, and more 
particularly the neck and face. It is very common in young 
persons, and especially in girls, in whom the skin is white 
and delicate ; to see small herpetic rings, about the size of a 
sixpence, on one or both the cheeks, and still more often on 
the chin.* 

Causes. — Herpes circinnatus generally attacks children, 
young persons and women. It is especially observable in per- 
sons of fair complexion and thin skin. Sometimes its appear- 
ance appears to be induced by cold; it may also be produced 
on the face by stimulating lotions or other applications. But 
in the generality of cases no special cause can be assigned for 
its occurrence. 

* There is a variety of herpes circinnatus that our authors do not appear 
to have seen. This does not heal with the disappearance of the first vesi- 
cles, but continually enlarges by the appearance of fresh vesicles on the 
>uter margin, and thus the disease often proceeds to a great extent, the in- 
ternal part of the ring healing whilst the ulcerous and vesicular circumfer- 
ence expands. This form occurs in warm climates ; Bateman states that it is 
dmost unknown in England.— Trans. 



108 VESICULAR DISEASES. 

A slight smarting and itching are the only symptoms that 
accompany the appearance of this eruption. 

Diagnosis.— Characters so distinct and well marked, would 
appear to preclude any mistake. Nevertheless, a small herpetic 
ring, in which the vesicles are only followed by a slight exfolia- 
tion, and having a red and circular form, may in some cases 
be mistaken for a leprous spot, deprived of its scales. But on 
the one part, the depression of the centre, and the prominence 
of the edges, and on the other, the unity of the surface, and 
above all, the existence of the remains of vesicles on the edges 
of the rings, will always suffice to prevent error, which, at all 
events cannot be of long continuance, as an herpetic ring is on 
the eve of healing, when the vesicles disappear. Besides, it is 
very rare that only a single leprous spot occurs, and they will 
probably be found on other parts of the body with more dis- 
tinct characters. 

There will perhaps be more difficulty in distinguishing this 
eruption from Porrigo scutulata, particularly as the name of 
ringworm has been applied to both diseases. But one, (Herpes 
circinnatusj is a vesicular affection, and gives rise to scales 
only; its duration is short, it is not contagious, and when it 
occupies the scalp, does not occasion a loss of the hair. The 
other, (Porrigo scutulata J is a pustular and contagious disor- 
der; its duration is long and indefinite; it occasions scabs, 
which gradually increase in thickness; it only occurs on the 
scalp, and rapidly occasions the loss of hair wherever the erup- 
tion is developed. 

The treatment of this disease is much the same as in the 
other species, except that great advantage is derived from lo- 
tions rendered alkaline by the addition of a small quantity of 
subcarbonate of soda or potash, (one or two drachms to the 
pint of water.) The itching and inflammation of the small 
herpetic rings that occur on the face, are often relieved by re- 
peated applications of saliva. Lotions made astringent by the 
addition of alum or sulphate of zinc, are also useful.* 

* It is said that the lime-water from gas-works, impregnated with the 
various absorbable products of the coal is very efficacious in removing ring- 



HERPES. 109 

It' the disease attacks several parts of the body simultaneous- 
ly, alkaline baths and mild laxatives should be ordered. 

Herpes Iris. 

This name has been given to an extremely rare variety of 
herpes, which appears in the form of small vesicular groups, 
surrounded by four erythematous rings of different shades of 
colour. Patients often compare this eruption to small cockades. 
Bateman was the first who described this affection with preci- 
sion, and ranged it in the genus herpes. 

It manifests itself by small spots, which are soon followed 
by zones of different colours. On the second day, a vesicle 
forms in the centre, which is soon surrounded by small ones. 
In the space of two or three days, the central vesicle becomes 
flattened; the fluid it contains grows turbid, and assumes a 
yellowish hue; the erythematous circles are more developed, 
and form four distinct rings surrounding a central vesicular 
group, thus making a disk of about the size of a shilling, on 
which is observable, (beginning from the central point to the 
circumference,) a reddish-brown ring, then one of a yellowish 
white, then a third of a deep red, and finally, one of rose- 
colour, which gradually fades into the natural colour of the 
skin. The number of these disks is sometimes considerable. 

The third of these rings is usually the narrowest; they may 
all, but especially the first, be covered with vesicles. 

The eruption terminates about the tenth or twelfth day, by 
an absorption of the fluid, and a slight desquamation. Some- 
times the vesicles break and form small scales, which soon se- 
parate and fall off. 

Herpes iris may occur on all parts of the body, but is more 
generally met with on the face, hands, insteps, fingers, neck, 
&c. It appears in some instances to select prominent parts, 
as the ankle. 

worm, a solution of sulph. cupri will often succeed where other applications 
have failed, and we have lately had strong- evidence of the utility of castor 
oil as a local application.— Trails. 

15 



110 VESICULAR DISEASES. 

Causes. — This eruption usually appears in children, wo- 
men, and persons of a fair complexion, without our being able 
to assign any special cause. It may occur simultaneously 
with other varieties of herpes. 

The only disease that can be confounded with it is the va- 
riety of roseola with multiplied rings. This latter eruption 
differs, however, by the greater size of the disks, which are 
sometimes larger than a dollar, and by the absence of vesicles. 
This is probably the eruption Willan placed among the exan- 
themata. This variety may, nevertheless, be mistaken, when 
the vesicles of the herpetic eruption have opened and disap- 
peared, but even then, in most cases, fragments of them may 
be discovered on a close inspection. 

This slight affection requires no treatment in a majority of 
cases, and if it does, the same remedies are applicable to it, as 
to herpes circinnatus. 

It is exceedingly rare, and among the multitude of diseases 
of the skin observed by Dr. Biett during many years, he has 
met with it but three or four times. 

Scabies. Itch. La Gale, 

Scabies is an essentially contagious eruption, characterized 
by vesicles, which are usually distinct, slightly acuminated, 
transparent at the summit, somewhat larger at their base, and 
accompanied with a greater or less degree of itching. Some 
authors have regarded and described it as a pustular affection, 
others have admitted one of its varieties to be of that nature, 
but it is an error. The pustules, which are only met with, 
in a few cases, are accidental, and for a long time M. Biett | 
has regarded the itch as vesicular. Nevertheless, under cer-, 
tain rare circumstances, some vesicles may become pustular. 

Scabies may occur on all parts of the body, except the face,! 
which is always exempt. But it particularly affects certain) 
situations, as the fingers, wrist, and in general all the bends of 
the limbs. It is a very common disease, and attacks all agesJ 
both sexes, appearing in all seasons, in all climates, and in all| 



SCABIES. Ill 

conditions of life; but it shows itself more particularly among 
the poor, where every thing seems to invite it, misery, want 
of clean linen, and an absolute neglect of cleanliness. When 
it appears among the rich, it has generally been introduced by 
domestics, &c. 

It never occurs spontaneously, and is not epidemic; this has 
been proved by numerous facts observed and recorded at the 
Hospital St. Louis. The epidemics of scabies, that have been 
so called, were, in all probability, vesicular affections of another 
kind, (eczema,) whose epidemic, also, is far from being ve- 
rified. It is never epidemic, but is essentially contagious. 

The time that elapses between the exposure to the contagion, 
and the invasion of the disease, offers some important points. 

In children it generally declares itself at the end of four or 
five days, but this varies. Thus, if they are feeble and deli- 
cate, the incubation is longer, and is very prompt where they 
are strong and hearty, appearing in two days. 

In adults it requires from eight to twelve days in the spring 
and summer, and from fifteen to twenty in winter. 

In old persons it is still longer in making its appearance, as 
their skin being dry and hard, offers less facility to its trans- 
mission and development. 

It is also a very long time in developing itself in persons 
who are affected with an inflammation of some internal organ. 

The vesicles first appear where the skin is fine and delicate, 
or the number of lymphatics greatest, as the interval of the 
fingers, in the bend of the arm, &c. Certain professions, 
however, cause some varieties; in blacksmiths, locksmiths, 
and dyers, the eruption does appear at first in the fingers 
or wrists, as their skin is rough and thickened in these places. 
On the contrary, the hands of tailors and seamstresses are pe- 
culiarly obnoxious to it. It often commences on the right hand 
in fencing masters. Cases are cited where it has been trans- 
mitted to the face by the collar of a cloak. Was this really 
the itch? We doubt it, for we have seen thousands of persons 
with this disorder, (they arrive in crowds at the Hospital St. 
Louis,) and have never met with this eruption on the face. 



1 12 VESICULAR DISEASES. 

Symptoms. — When scabies has been communicated, the 
individual who is attacked experiences an itching at the places 
where contact took place. This pruritus increases in the even- 
ing, from the heat of the bed, and by the use of spirituous 
liquors or high seasoned food. Vesicles make their appearance, 
which slowly increase in size and numbers. They are point- 
ed, transparent at top, present a slight red tinge in young per- 
sons, and contain a serous and viscous fluid. If the patient is 
feeble, the eruption makes but little progress, but if the con- 
trary be the case, it rapidly extends. It occurs in the bends 
of the limbs, in the intervals between the fingers, in the arm- 
pits, and sometimes on the abdomen. It may be general, ex- 
cept on the face, but is usually confined to a small surface, on 
the abdomen or arms. In some cases it merely consists of a 
few vesicles, dispersed here and there on the wrists and between 
the fingers. 

If the vesicles are few, the itching they create is slight, and 
they preserve for a long time their original form. But if they 
increase rapidly, or if they take place in subjects whose skin 
is fine and delicate, the itching becomes intolerable. The pa- 
tients, in scratching themselves, tear the vesicles, the liquid 
they contain flows out, and they are replaced by a multitude 
of small, red, inflamed spots. Finally, in some cases, the ac- 
tion of the nails, determined by the itching, augments the in- 
flammation to such a degree that the disease may become com- 
plicated with pustules of impetigo, or even ecthyma, but this 
is never observed except in young, vigorous, and sanguine 
persons, or from an excess in food. 

Whatever may be the extent of the eruption, it never occa- 
sions those serious symptoms that have been attributed to it. 
Other eruptions, as well as the inflammations of internal organs 
that may accompany it, are only complications. 

Causes. — These are predisposing or proximate, youth, san- 
guine temperament, the sex, the handling of woollen goods, 
the spring, the summer, and warm climates, all appear to pre- 
dispose to this complaint. It more particularly affects chil- 
dren and young persons, and the reason, as has been justly ob- 



SCABIES. 113 

served by M. Biett, is the greater proportion of individuals of 
these ages that exist. It results from the records kept at the 
Hospital St. Louis, that it is much more frequent among men. 
ro what is this to be attributed? Are they more predisposed 
to it? No, but they are much more exposed to its contagion. 

Lymphatic and sanguine temperaments are very obnoxious 
to its attacks; it rarely occurs in persons of bilious habits. But 
this may be, because these exist in a less proportion. Final- 
ly, it is frequently observed in tailors, seamstresses, mattress 
makers, &c. 

As to the proximate cause, it is still wholly unknown. Sca- 
bies has in turn been attributed to an acid principle, to a pe- 
culiar fermentation, and finally to the presence of insects. This 
latter hypothesis is still admitted by a great number of physi- 
cians. Nevertheless, if we cannot affirm that they do not cause 
it, we at least are far from crediting it. Without impugning 
the good faith of those who believe in it, we are of opinion, 
that in a majority of cases they have mistaken a pedicular dis- 
ease for itch; even Morgagni's account may be referred to this 
head. Let it be as it may, they were first admitted by Aven- 
zoar, afterwards by Ingrassias and Joubert, then described at 
some length by Moufet, drawn from nature by Hauptmann, and 
finally the development of the insect, and the manner in 
which it forms the vesicles, given in detail by Redi, in the 
seventeenth century; this acarus has also been classed and de- 
scribed by Linngeus, Degur, Fabricius, and Latreille. But its 
existence was still doubted, when, in 1812, the experiments 
of M. Gales, formerly apothecary to the Hospital St. Louis, 
were so successful, that they appear to destroy all uncertainty. 
His first researches were fruitless, but the latter ones were 
crowned with such success, that he collected more than three 
hundred of them, and even described their generation, man- 
ner of laying their eggs, &c. These observations present so 
many marks of authenticity; Mr. Gales was assisted by so 
many credible witnesses, that no person can doubt what he has 
advanced. Nevertheless, these experiments have since been 
repeated by individuals who possessed the necessary requi- 



114 VESICULAR DISEASES. 

sites of faithful observers in as high a degree as Mr. Gales, 
yet they have never arrived at the same results. 

In 1813, Alibert had them undertaken, by a skilful person, 
but he could find no insects. It is to be remarked, however, 
that lately in his history of la Psoride pustuleuse, (itch,) 
this author appears to retract his opinion, and to admit the ex- 
istence of the acarus. 

In 1818, 1819, &c. M. Biett repeated these experiments 
himself, in which he used the best microscopes, even that 
of Amici on the horizontal plan. These researches were 
made on a great number of individuals, and under the most 
favourable conditions to discover the insect if it really exist- 
ed. But he has never succeeded in detecting it. The same 
result has attended observations made in other countries. * 

It is therefore desirable that M. Gales, who has arrived to 
such a degree of quickness of sight, that he can discover with 
the naked eye the vesicles that contain the insects, would 
again visit the Hospital of St. Louis, and reiterate experi- 
ments which have hitherto been so successful. Till then, we 
shall think ourselves justified in believing that the acarus does 
not exist. 

Diagnosis. — If itch is usually to be recognised with ease, 
cases also exist where it is very difficult to distinguish it from 
eruptions of a wholly different character, and which, more- 
over, are not contagious; it is, above all, of extreme impor- 
tance to form a true diagnosis of this eruption, as the least er- 
ror may not only compromit the reputation of a physician, 
but it may also on the one part give rise to unjust suspicions, 
or even deprive an individual of his situation, &c. or on the 
other, lull the apprehensions of a family as to the nature of a 
disease, the rapid contagion of which may soon involve every 
person in the house. 

The eruption most generally confounded with scabies is 

* Bateman appears to believe in the existence of these insects, but ac- 
knowledges that he has never been able to detect them. Heberden was 
equally unsuccessful, and he was informed by the best microscopic observ- 
ers of his day, that they were in the same predicament.— Thans. 



SCABIES. 115 

prurigo. But independently of the primary characters, that 
are always present, as papulae in one, and vesicles in the other, 
the usual seat of prurigo is in the back and shoulders, as well 
as the limbs on their surface of extension; whilst we have seen, 
that itch occurs most generally on the surfaces of flexure. In 
prurigo the papulae are generally lacinated, and terminat- 
ed by a small, dry, black, or blackish clot of blood. The ve- 
sicles of itch, on the contrary, when they break, are sur- 
mounted by a small, thin, yellowish scale. The pruritus is 
more violent and burning in prurigo, and finally, this disease is 
not contagious. 

Lichen simplex may also be mistaken for scabies, but with 
a little attention it will be perceived that it is constituted of 
papulae, that these are ordinarily almost confluent, which 
is never the case in itch; that they preserve the natural colour 
of the skin, whilst the vesicles of scabies are slightly rosace- 
ous; that when it exists on the hands, (where above all it may 
be mistaken,) it appears on the backs, and not between the fin- 
gers, as the vesicles in itch; that it usually occupies the out- 
side of the limbs; that there is but little itching, and that it is 
not contagious. 

It may be distinguished from lichen urticatus with still 
more ease, although in this disease the itching is violent, but 
the papulae being more inflamed, larger, and more prominent, 
are easily recognised. 

Finally, scabies may be confounded with eczema, particu- 
larly with E. simplex, but the vesicles are flattened in this 
disease, whilst they are pointed in itch. They are more or 
less grouped in eczema, but are generally distinct in itch. The 
pruritus of eczema is a kind of general smarting, very differ- 
ent from the exacerbations characterizing that of scabies. Ec- 
zema is not contagious, at least in the generality of cases. 

Scabies may be complicated with several eruptions of an en- 
tirely different order. Its most usual complication is with ec- 
zema, which is generally occasioned by lotions or irritating 
ointments; this is the eruption that is caused by the remedies 
of certain quacks, who persuade the public that they can make 
the itch strike out, 



Ilfi VESICULAR DISEASES. 

The irritation of the skin may be so violent and intense as 
to cause the itch to be combined with pustules of impetigo or 
ecthyma, which generally manifest themselves where the ve- 
sicles are in the greatest number; these cases have been 
mistaken for pustular itch, but it is a mistake, they are only 
complications, and are met with, especially in young, san- 
guine, and irritable subjects. 

The inflammation, when exasperated by the action of the 
nails, may extend to the cellular tissue, and it is not uncom- 
mon to see a great number of boils supervene on the original 
disease. Sometimes vesicles of scabies, pustules of impetigo 
and ecthyma, and also boils, are to be seen on a patient at the 
same moment. In some very rare cases, small papulae of li- 
chen may occur with the itch, a short time after its eruption. 
Inflammations of the internal organs are very rare in this dis- 
ease, and when they do exist, they are evidently concomi- 
tant diseases, and if some cases of inflammation of the gastro- 
intestinal mucous membrane have coincided with the disap- 
pearance of the eruption; is it to this disappearance that they 
should be attributed, or is it not rather to the internal dis- 
ease, that the retrocession of the cutaneous affection should be 
attributed? 

Finally, itch may exist with syphilis or scrofula, without 
these diseases being in the least influenced by each other. 
Scurvy, in some exceedingly rare cases, imparts a livid colour 
to the vesicles of scabies. 

Prognosis.— Scabies is a slight disease; its complications 
may, however, occasion some violent symptoms, but it never 
is itself accompanied with the danger spoken of by some au- 
thors. Itch never terminates spontaneously, it never has a 
crisis, and the cases that have been cited as presenting these 
peculiarities, were evidently of a different disease; it never oc- 
casions death, or ends in another disease; sometimes it hap- 
pens that another eruption may exist with it, or be developed 
during its treatment, and remain after its disappearance, but 
this is not a conversion of one affection into another. Left to 
itself, it may continue for years, or even during life. When 
subjected to a rational treatment, its duration varies from ten 



SCABIES. 117 

days to several months, according to the complications, which 
may oppose the proper treatment, and greatly retard the 
cure. 

Treatment. — Itch is a purely local disease, and hence, only 
requires local remedies; bleeding and purgatives, which for- 
merly were considered as essential in its treatment, are now 
seldom employed, and only to fulfil particular indications. 
Thus the local treatment will be much aided by venesection, 
in a young, sanguine and robust person, in whom the eruption 
is general, and accompanied with violent itching: or by the 
administration of a purgative, either at the commencement or 
during the course of the treatment, in a person of a lymphatic 
and feeble constitution, in whom an habitual constipation ex- 
ists. The local means that have been proposed for the cure of 
itch, are too numerous to be all enumerated, we shall content 
ourselves with pointing out such as are dangerous, and those 
which may be employed in a majority of cases. 

In general, the mercurial preparations, and particularly the 
ung. citrin. and the quintescence anti-psorique, which appears 
to have corros. sublim. as its base, may be replaced with much 
advantage by milder means, as they often induce symptoms 
of a very dangerous character. Thus, independently of the 
eruptions they generally occasion, which retard the cure, 
they almost always cause swellings of the salivary glands, sa- 
livation, and sometimes, even glossitis, &c. They should 
be discarded in the treatment of itch. Among the remedies 
that experience has shown to be peculiarly useful, we would 
mention in the first place, the powder of Pyhorel, this is sul- 
phuret of lime finely powdered, which is to be incorporated 
with a little sweet oil, and half a drachm to be rubbed over 
the eruption, with the palm of the hand, twice a day. This 
generally is effectual in about fifteen days, but is only suited 
to recent cases, and where they are of moderate extent. 

The liniment of Javelot is very apt to occasion other erup- 
tions. Cure in about fifteen days. Dupuytrert s lotion con- 
sists of four ounces of sulphuret of potash, in a pound and a 
half of water, with the addition of half an ounce of sulphuric 

16 



118 VESICULAR DISEASES. 

acid. The patients are to wash twice a day with this solu- 
tion, those parts which are covered with vesicles ; this is an 
advantageous and commodious plan, for patients who do not like 
ointments, but will not suit those of an irritable temperament, 
as it often occasions very painful smarting, and besides, it does 
not usually effect a cure under sixteen days Hellebore oint- 
ment mixed in the proportion of a sixteenth with axunge: 
this preparation has been found by M. Biett, from observa- 
tions on a great number of cases, to cure in about thirteen 
days and a half, and never to occasion accidents. 

But of all remedies, that which has most generally and 
promptly succeeded without inducing other eruptions, is Hel- 
merich's ointment, as modified, and almost exclusively em- 
ployed by M. Biett for several years past. It consists of 
sulph. sub. Jij. sub. carb. potass, %i. axunge, §i. ; half an 
ounce of this is to be rubbed over all those parts on which the 
eruption may exist, every morning and evening. The patient 
should also take a warm bath every day, or at least every other 
day. The usual time of treatment is twelve days. 

In children, lotions of soap and water, and artificial sulphur- 
ous baths, are all that are requisite. Baths and fumigations 
are excellent auxiliaries in the treatment of scabies, but cannot 
be depended on alone, as the treatment is much prolonged. 
Sulphurous baths effect a cure more promptly, and never occa- 
sion other symptoms, the usual time of treatment is twenty- 
five days. Sulphurous fumigations are far from producing the 
marvellous cures that have been attributed to them; they are 
often useful as auxiliaries, particularly in old persons, but when 
used alone, the average duration of the treatment is thirty- 
three days, one fumigation being used each day, but this me- 
thod is fatiguing, and will seldom be submitted to by patients. 
What are we to think of those, who advise two fumigations 
per day, in order to hasten the cure? 

In general, simple baths only, are used in addition to the lo- 
cal means in the treatment of itch. But there are cases in 
which new vesicles are constantly formed, and where they 
dry up and disappear very slowly. In such a condition of 






SCABIES. 119 

things, it is often useful to alternate them with sulphurous fu- 
migations, or what is still better, with sulphurous baths. Al- 
kaline baths are peculiarly advantageous, where the patient 
experiences violent attacks of itching. 

Whatever plan may be adopted, if the disease be compli- 
cated with some other eruption, eczema for instance, the treat- 
ment must be interrupted ; and diluent, or slightly acidulated 
drinks administered. Sometimes scabies is accompanied at its 
commencement, or afterwards becomes combined with impe- 
tigo or ecthyma. In such case, lotions and irritating oint- 
ments must not be used, on the contrary, simple baths, and 
laxative draughts, must be prescribed, and it is often useful to 
employ local baths of scalded bran, decoction of mallows, or 
greasy pot liquor, (eau de vaisselle grasse.J To insure a 
cure, and prevent a relapse, the clothes, particularly those of 
woollen, should be purified by smoking them with sulphur, 
and the use of simple baths continued for some days. The pa- 
tient should also change his linen as often as possible. * 

* The bases of most of the quack remedies used in this country for the 
cure of itch, are sulphur or mercury, and sometimes both combined. The 
juice of the hemlock has been found useful in this complaint; the pustules 
are to be bathed with it for five or six days; this remedy is highly spoken of 
by Dr. Pelligrini. — London Medical Gazette, Vol. I, No. 6. 

A solution of the chlorides of lime, soda, and potash, in the proportion of 
3'rij, to distilled water, Jbi. is also said to cure this loathsome disorder in six 
to ten days, without inducing- any unpleasant symptoms. — Thaws. 



( 120 ) 



ORDER III. 



BULLAR DISEASES. 



BULLJE. 



THE diseases arranged in this order, are characterized by- 
elevations of the cuticle, sometimes of a large size, filled with 
a serous or sero-purulent fluid. These tumours, known under 
the name of bullae, are usually of a circular form, their base is 
large, and their size, which varies from that of a pea to that of 
a goose-egg, distinguishes them from vesicles which are of in- 
finitely less volume. 

The bullar inflammations are, (properly speaking, ) but two 
in number, pemphigus and rupia. The latter of these has 
been classed by Bateman among the vesicular diseases, but 
from observations made by Biett for several years, it rather 
appears to appertain to the bullar affections. In some diseases 
of the skin, (not belonging to this order,) analogous lesions 
are observable, but then their development is' entirely acci- 
dental; they are only simple complications, which cannot pre- 
vail over the elementary characters of the original disease, 
which always predominates in a marked manner. Thus, in a 
variety of herpes, (zona,) some vesicles acquire a larger size 
than the others, and constitute real bullae. But the vesi- 
cles are in much the greatest number; besides which, as we 
have before said, in speaking of herpes, all the other symp- 
toms are far from being analogous to those of the bullar in- 
flammations. Hence it is an unfortunate innovation in some 
authors, overlooking all positive and fixed characters, and at- 
tending to anomalous symptoms alone, to have classed Herpes 
zoster among the bullae. The appearance of this same lesion 
in erysipelas, should also be looked upon as fortuitous. 

The bullar inflammations, though sometimes occurring in an 



BVLLM. 121 

acute form, are usually chronic; they may attack in succession 
all parts of the body ; for although they may affect large sur- 
faces, it is rare for them to cover the whole skin at the same 
time; but, in the generality of cases they are confined to the 
limbs, and more especially to the lower extremities. Their 
duration varies from one or two weeks to several months, and 
they may even exist for an indefinite period. 

Symptoms. — The appearance of bullae is often preceded by 
a greater or less degree of redness, but in many cases the cu- 
ticle becomes vesicated without any erythematous redness be- 
ing previously observed. This vesication is at first of little 
extent, but its base gradually enlarges, and the bleb acquires 
a considerable size; this usually occurs in forty-eight hours. 
The bullae are tense on their first appearance, but they after- 
wards become flaccid, and at the same time the fluid they con- 
tain thickens, in other cases they break. In all instances they 
open more or less promptly according to the thickness of the 
cuticle, their distention, seat, and movements of the patient, 
and are replaced by scabs, which are sometimes very thin, and 
at others of considerable thickness. Those bullae which are 
developed on the face are usually very small; these rapidly 
break, and are followed by scabs somewhat resembling those 
of impetigo. In some cases, the bullae are replaced by super- 
ficial ulcerations, which, however, are deep in rupia. 

Causes. — The causes of the bullar affections are generally 
difficult to ascertain; they appear, in a majority of cases, to 
depend on some derangement of the constitution. 

Diagnosis. — These inflammations are usually, to be easily 
distinguished. Vesicles which maybe mistaken for them, dif- 
fer in the much smaller size of the vesications. The diagnosis 
is more difficult when the bullae have broken and are replaced 
by scabs of different thicknesses. But the essential characters 
of each species will suffice to mark whether they have or have 
not been preceded by bullae; the same will apply to the traces 
the bullar affections leave on the skin. Nevertheless, it is by 
the aid of negative characters that we must proceed in these 
cases, which often require much practical knowledge to esta- 
blish a true diagnosis. 



122 BULLAR DISEASES. 

Prognosis. — The bullar inflammations sometimes become 
serious, particularly when they have existed for a length of 
time, in persons enfeebled by age or an injured constitution; 
under these circumstances they often accompany a chronic af- 
fection of some internal organ, and especially of the liver. 

They sometimes require an antiphlogistic treatment; at 
others, on the contrary, recourse must be had to tonics and 
ferruginous preparations; finally, they require, above all, good 
nursing and strict attention. 

Pemphigus. 

By the term pemphigus, from f fi*P<£, bulla, is meant an 
affection characterized by the presence, on one or more parts 
of the body, of bullae of different sizes, but generally very 
large, being sometimes upwards of two inches in diameter, 
containing a serous fluid which is at first very limpid, but soon 
becomes reddish; these bullae are mostly isolated, but in great 
numbers, and the disease is prolonged by successive erup- 
tions, and which always give rise to thin scabs and superficial 
ulcerations. 

Willan was induced from the vagueness and discrepancies 
that reign in the descriptions, that previous writers had given 
of this disease, to deny its existence, it having been described 
as an eruption of bullae with a red and inflamed base, accom- 
panied with fever. He only admits the chronic form, under 
the name of pompholix, and defines it as an eruption of bullae, 
" without any inflammation round them, and without fever." 
Bateman appears to have adopted the opinion of Willan, on 
the non-existence of an acute bullar disease, and Plumbe, in 
admitting that pompholix may offer acute symptoms, denies 
the occurrence of pemphigus. Nevertheless, Gilbert in his 
excellent Monographic sur le Pemphigus, has proved that 
this disease, which he describes with astonishing precision, 
often appears with the symptoms that Willan has doubted. 
From his authority, and from a number of facts observed in 
the Hospital of St. Louis, M. Biett admits the existence of 
acute pemphigus. 



PEMPHIGUS. 123 

Pemphigus presents two distinct varieties, according as it 
is acute or chronic. 

Acute pemphigus maybe partial, and only occupy a single 
region, but it is generally spread over a considerable space, 
and may even cover the greater part of the surface of the body. 
In these cases the bullae are almost all distinct, a few only be- 
ing confluent. Sometimes the precursory symptoms are very 
ight, and only consist in a state of general uneasiness, accom- 
panied with violent itching of the skin, and a slight accelera- 
tion of pulse. Sometimes, however, the skin is hot and 
burning, and there is thirst, anorexia, chills, and great fre- 
quency of the pulse. This state lasts from twenty-four to 
forty-eight hours, sometimes even for three days. The erup- 
tion soon commences, consisting at first of small, red circular 
spots, which soon augment in size, and become covered with 
vesications, resulting from the secretion of a serous fluid from 
the whole or part of the spot elevating the cuticle. Sometimes 
this takes place soon after the appearance of the eruption; at 
other times it is some hours before the bullae make their ap- 
pearance. In some cases, the bullae cover the whole of the 
inflamed surface, and present the appearance of small, trans- 
parent, distinct tumours, from the size of a pea to that of a 
hazelnut, and of a circular form, in other instances, on the 
contrary, the cuticle does not become elevated over the whole 
extent of the red spot, but bulla merely appears about its cen- 
tre; thus, on a spot equal in size to a quarter of a dollar, a 
bulla of only the size of a pea, is to be seen, whilst under 
other circumstances, the serous vesication is merely sur- 
rounded by an areola of a few lines in breadth. Finally, 
in other cases, erythematous spots occur, on which no bullae 
are formed; but then in passing the finger over them, a slight 
tumefaction may be felt, and if they are rubbed for a short 
time, the cuticle becomes detached, and a slight exudation of 
serous fluid takes place under it. The redness of the large 
areolae is very vivid during the first few days, whilst that of the 
invesicated spots is very moderate: the intervening skin always 
-emains healthy. We have dilated on this redness from the 



124 BULLAR DISEASES. 

circumstance of its existence being denied by some authors, 
as we already observed at the commencement of this chapter. 
Sometimes several bullae unite and form a tumour as large 
as a goose-egg. When they have acquired their full size, they 
contain a yellowish fluid, and soon begin to shrivel, and this 
fluid becomes turbid. Sometimes they break in twenty-four 
or forty-eight hours, though they usually last for several days. 
They are followed by small, thin, brownish crusts, which be- 
gin to form before the redness has disappeared. Sometimes, 
however, only small, dry, white, epidermic lamellae are 

formed. 

The general symptoms that accompany this disease are 
slight, not requiring the patients to keep their bed, but in 
some cases they may be very severe. We have seen a pa- 
tient in the Hospital of St. Louis, in whom this eruption was 
attended, not only with a gastro-intestinal irritation, but also 
with a pulmonary catarrh, an ophthalmia, and a very acute 
inflammation of the urethra. His tongue was much swelled, 
and his lips covered with blackish crusts. All these symp- 
toms, as well as the eruption, entirely disappeared in the 
course of a month. 

The usual duration of acute pemphigus varies from one to 
three weeks. It sometimes attacks children, and with the 
same symptoms. Pemphigus infantilis or gangrenosa s, ap- 
pears to us to belong to Rupia escharotica. 

The Pomp holix solitarius of Willan, seems to be a variety 
of acute pemphigus. The appearance of the bulla is preceded 
by a sensation of tingling; its course is rapid, and the epider- 
mis is distended with several ounces of lymph. This vesica- 
tion breaks within forty-eight hours, and leaves a superficial 
ulceration. Near this, another bulla arises in aj'day or two, 
and pursues the same march, and is sometimes followed by 
two or three others in succession, so that the disease may last 
from eight to ten days. This variety is extremely rare; it 
may also exist in a chronic state, an interesting case of which 
was exhibited by M. Biett in one of his clinical lectures. 

Chronic pemphigvs, frompholix diutinns, WiHan. Bar 



PEMPHRJUS. 125 

Ire phlyclenoidc, Alibert,) is a more common disease than the 
acute form. It is observed in adults, and especially in elderly- 
men, but rarely occurs in women. This affection may simul- 
taneously attack all parts of the body, but sometimes is confined 
to a small space. Permanent febrile symptoms do not occur 
in this form, without the cutaneous affection is very extensive, 
but it may be indefinitely prolonged by successive eruptions. 

Some days before the appearance of the bullae, the patient 
experiences lassitude, pains in the limbs, and languor, but these 
symptoms are slight, and scarcely attract attention. Numer- 
ous red pimple-like points appear, accompanied with a sensa- 
tion of tingling. In the centre of each small spot, the epi- 
dermis is elevated. The base gradually enlarges, so as often 
to form in a few hours only, irregular vesications of the size 
of a hazelnut, or even of a walnut; the distention goes on in- 
creasing, and at the end of two or three days, these bullae may 
attain the size of an egg. Either from their size, or from 
the motions of the patient, some of them open and pour out a 
yellowish lymph; in such case, the cuticle wrinkles and shrivels, 
or becoming partly detached, rolls up and lays bare a portion of 
the inflamed surface; it may also become entirely separated, and 
leave a red and painful ulceration, which ends in a slight ex- 
foliation. Towards the third or fourth day, those bullae 
which have not broken, begin to wither and lose their transpa- 
rency, whilst the fluid they contain becomes reddish; the cu- 
ticle loses its tension, and from being macerated in the fluid, 
it acquires an opaque, whitish colour, and forms small, brown- 
ish, thin, flat crusts. 

Finally, other bullae appear near the first, and follow the 
same course, so that, on the same individual, there may be 
seen bullae distended by a yellowish, transparent lymph, thin 
lamellar scabs, and irregular spots of different sizes, which are 
slightly excoriated. Moreover, the skin of the patient in 
whom all these stages of the disease are visible, presents 
a peculiar appearance. Such is the most usual course of 
chronic pemphigus, and which may thus be prolonged for 
months. ^ 

17 



126 BTTLLAR DISEASES. 

In some rare cases, the eruption occupies the whole surface 
of the body. The bullae are confluent; they unite, the fluid 
thickens, becomes purulent, and the whole body is covered 
with yellowish crusts, which may be mistaken for those of 
impetigo; these scabs are thin, and generally present at their 
circumference, or in their form, some mark, denoting that they 
have succeeded to bullae. In fact, some of them being ex- 
tremely thin, are arched, and their circumference, from their 
extreme tenuity, presents a wrinkled form, like that of the 
corrugated skin. They constitute an almost continuous co- 
vering, the intersections of which are formed of scales, which 
somewhat overlay each other. This variety is sometimes con- 
fined to the face, which otherwise is not a common seat of this 
eruption. 

Sometimes the development of the first bullae is preceded 
by the appearance of red, circular spots, as in acute pemphi- 
gus, but the consequent eruption do not present analogous phe- 
nomena, and vice versa; at other times the secondary erup- 
tions may have erythematous areolae. The disease may also 
be confined to a single point; we have seen in M. Biett's wards 
a man of thirty years of age, who had been affected from his 
infancy with a pemphigus, sometimes on one spot, sometimes 
on another, and the lower part of whose legs presented a pur- 
plish-red appearance, similar to that produced by atonic ul- 
cers. For a great number of years, bullae of pemphigus were 
continually developed on this spot, sometimes of the size of an 
almond, at others, of a large nut; in some instances they even 
became as large as the palm of the hand; in such case, the der- 
moid membrane was denuded to a great extent, and its unpro- 
tected surface offered every appearance of a large atonic ulcer, 
whose cicatrization would take place but slowly; but this was 
not the case, as this spot often healed in one day, when fresh 
bullae appeared, and followed the same course. 

In severe cases the patient is obliged to keep his bed, though 
fever rarely occurs; but on the contrary, when the eruption is 
of moderate extent, this is not necessary, and the vesications 
go on, appearing on different spots for an indefinite period* 



PEMPHIGUS. 127 

Pemphigus may exist with a multitude of other eruptions, 
but it most usually occurs with herpes and prurigo. In this 
last complication, (pomp holix pruriginosus, Will.) the pa- 
tient experiences violent itching. Chronic pemphigus may 
be complicated with a variety of chronic diseases of the inter- 
nal organs. 

From what we have said of the course of pemphigus, some 
idea may be formed of its indefinite duration; it varies from 
one, two, or three weeks, to months and years. Sometimes 
it appears in the summer, and ceases towards the latter end of 
the autumn. 

Pemphigus generally terminates by a restoration of the 
health, but may occasion death ; this is usually the result of 
some serious complication, as of a general or local dropsy, 
which frequently occurs in elderly persons, and who may have 
been afflicted with pemphigus for many years, or from chronic 
inflammations of the digestive apparatus. 

Dissection. — We have been enabled to examine several bo- 
dies at the Hospital of St. Louis, but have never discovered 
bullae on the mucous membranes, particularly of the pharynx; 
on the contrary, we have generally found these tissues pale, 
with an effusion of serum in the thorax. We have several 
times found the liver enlarged, and M. Biett has informed us, 
that he has frequently known this anatomical lesion to coexist 
with pemphigus. 

Causes. — Pemphigus may attack all ages, but particularly 
adults and old persons; it is met with in both sexes, but females 
appear less subject to it than males. Some persons are affect- 
ed with it several times, at irregular intervals; in others, the 
bullae of chronic pemphigus may continue to appear for an in- 
definite period. Under some circumstances it is endemic, or 
rather, may attack a great number of individuals about the 
same time. The acute form often occurs during the summer, 
in persons who are exposed to the sun; dentition, excesses of 
the table, &c. have appeared in certain cases to exercise a 
marked influence on its development; it only attacks young 
subjects. Chronic pemphigus particularly affects the aged, and 



128 BTTLLAR DISEASES. 

individuals of a broken constitution. A poor and scanty nour- 
ishment, laborious employments, want of sleep, and living in 
low and damp situations, all appear to predispose to it. It has 
also been known to arise during chronic affections, either of a 
rheumatic character, or of the abdominal viscera. 

Diagnosis. — The presence of bullae, which are generally 
isolated, and succeeded by thin, lamellar scabs, which cover 
the unprotected dermis, either entirely, or in part, will always 
prevent pemphigus from being confounded with other dis- 
eases. 

It is distinguished from rupia simplex, from the vesications 
in the latter being rare, and followed by true ulcerations, 
which are covered by thick and prominent crusts. 

In ecthyma the epidermis is sometimes raised to a certain 
extent by pus, and forms a kind of bulla, but in this case the 
fluid is purulent and not serous. The elevated cuticle presents 
a brown spot at its centre, added to which, pustules of ecthy- 
ma, in various stages of progress, may be found on other 
parts. 

In herpes the vesicles are always united in a group on a red 
and inflamed surface, whilst the bullae of pemphigus are dis- 
tinct, and in the majority of cases are not surrounded with an 
areola. Nevertheless, in some rare instances, a few of the 
bullae in acute pemphigus may be small and conglomerated in 
various spots, and thus resemble the groups of herpes phlycte- 
nodes, but then, distinct bullae, possessing all their distinctive 
characters may be seen in other places; besides which these 
groups are formed of a union of bullae, which, although small, 
are always larger than the vesicles that constitute those of 
herpes. The bullae which occur on an erysipelatous surface, 
differ from pemphigus by the presence of the erysipelas itself, 
and of which they form an accidental character. In some cases 
the scabs that succeed to pemphigus may be mistaken for those 
of impetigo, but if they should even form, as above described, 
an almost entire envelope, they cannot be mistaken, for impe- 
tigo is generally confined to a certain space, and rarely covers 
the whole body. Besides, the scabs of the pustular inflamma- 



PEMPHIGUS. 129 

tion are rugose and thick, whereas here they are thin, some- 
times arched in the centre, corrugated at the circumference, 
and resembling in size and extent the bulla? to which they have 
succeeded. 

The spots left by this eruption present some characteristic 
appearances, which may be appreciated by those who are vers- 
ed in diseases of the skin, but which are difficult to describe. 
Thus we have several times seen M. Biett draw a diagnosis 
from them, as to the previous existence of a bullar eruption, 
which had been cured some time before. They are of a dull 
red, separated from each other, of an irregular form, of varia- 
ble size, and forming slight exfoliations from time to time. 

Prognosis. — Acute pemphigus is never fatal of itself, it al- 
ways terminates happily, except from some complication. The 
prognosis of chronic pemphigus varies according to the indi- 
viduals attacked; its danger depends on the extent of the erup- 
tion, its successive attacks, and whether it occurs in persons 
enfeebled by age, misery, or debauchery. It may be advanced, 
that chronic pemphigus usually indicates a deranged state of 
the constitution. Its severity is generally in direct relation to 
that of the chronic diseases with which it may be complicated. 

Treatment. — Acute pemphigus is a mild disease, and 
health is often restored by the aid of diet, diluent drinks, and 
rest. But if symptoms of acute inflammation exist, or if the 
eruption is extensive, tepid baths, venesection, or the applica- 
tion of leeches to the anus may be employed with advantage. 

In chronic pemphigus, the treatment should at first be an- 
tiphlogistic, but with caution; diluent and acidulated drinks, 
(barley water with 3ss. of sulphuric acid,) and afterwards te- 
pid baths, are the best means at the commencement. At the 
same time, if the pain is acute, it may be assuaged by emollient 
applications and the administration of opiates, particularly 
where there is restlessness and want of sleep. This remedy 
is above all to be used if there should be diarrhoea, dull pain in 
the abdomen, &c. Blood-letting must also be resorted to, if 
an obstinate cough should supervene, accompanied with spitting 
of blood, or other symptoms of an inflammation of important 



130 



BULLAR DISEASES, 



organs. But chronic pemphigus should not be considered as 
a purely inflammatory affection, and if, notwithstanding the 
use of the above remedies, fresh eruptions should continue to 
appear, the strength of the patient must be supported by gene- 
rous diet, and the use of the acids; he may take, for example, a 
decoction of cinchona with the addition of a drachm of sulphu- 
ric acid to the pint, or some ferruginous preparations, Passy 
water, pills of sulphate of iron, chalybeate wine, &c. 

The use of these remedies should not be restricted to elder- 
ly persons; they must also be employed in the young, when 
the eruption is of long continuance, and we have observed se- 
veral cases of this kind in the Hospital of St. Louis, in which, 
the tonic treatment produced the happiest effects; but they 
must be used with care, and adapted to the constitution and 
state of the patient. 



Rupia. 

Rupia, from pvires, sordes, is characterized by distinct, flat- 
tened bullae of different sizes, filled with a fluid which is some- 
times serous, and sometimes purulent and blackish, succeeded 
by thick scabs and ulcerations of various degrees of depth. 

This affection is very analogous to ecthyma, of which, in 
some cases, it appears to be only a variety, as has been observed 
by Bateman andPlumbe; M. Biettis also of the same opinion. 

The lower extremities are the usual seat of rupia, but it may 
occur on the loins, thighs, superior extremities, and other 
parts of the body. In rupia but few bullae make their appear- 
ance at a time, and generally widely separated from each other. 
It usually occurs in a chronic form, and its duration varies from 
two weeks to several months. 

Several varieties have been established, but they in reality 
only differ from each other, in their extent and intensity. 

Rupia simplex, (Willan,) is usually met with in persons 
who suffer from want of clothing and food, and are enfeebled 
by misery, privations, and uncleanliness. It is also often 
seen after small pox, scarlet fever, or measles. 



RUPIA. 131 

It appears in the form of round, flat bulla?, about the size of 
a shilling, which are developed without any previous inflam- 
mation. They contain a transj)arent serous fluid which soon 
thickens and becomes purulent; after this it shrivels and 
the fluid dries, forming a brown, rugose scab, thicker in the 
centre than at its circumference, where it is continuous with 
the surrounding cuticle, which is slightly elevated. A super- 
ficial ulceration exists under this scab, which falls off in a few 
days, and cicatrization speedily takes place; but in some cases 
a round ulcerated spot remains for some days and forms scales, 
which fall off, and are renewed several times, and after cica- 
trization has been effected, there still exists a livid red colour 
in the diseased spot. This eruption often accompanies certain 
cases of ecthyma where the suppuration is abundant, and in 
which the cuticle is elevated to a certain extent by a very fluid 
pus, forming a real bulla. The larger of these are soon trans- 
formed into thick scabs, elevated at their centre and thin at their 
circumference, which is continuous with the separated epidermis. 

2d. The second variety, (Rupia prominens, Wi\\.) differs 
from R. simplex by the greater size of the bullae, the depth 
of the ulceration and thickness of the scab. It much resembles 
the chronic form of ecthyma described by Willan under the 
name of Ecthyma cachecticum. It is often observed in per- 
sons of a broken constitution, and enfeebled by age or intem- 
perance. Its usual seat is in the lower extremities, and may 
exist but on one spot, whilst in other cases the bullae are nu- 
merous, but always distinct and widely separated. 

Rupia prominens commences with a circumscribed inflam- 
mation of the skin, followed by the appearance of a bulla, 
(which is sometimes rapid in its progress,) containing a serous 
fluid; but usually, the cuticle is slowly separated from the 
dermis, not by a yellowish serum, but by a blackish and 
thick liquid. In some cases, resolution may take place and 
the inflammation disappear, before the formation of scabs. But 
in general the fluid contained in the vesication concretes with 
rapidity, and forms a fluted scab, the size and thickness of 
which, though at first inconsiderable, soon augments. The cir- 



132 BULLAR DISEASES. 

cumference of it is surrounded by a red border of some lines 
in width, upon which a new scab arises and adds to the size 
of the former. The areola slowly extends itself, and fresh 
scabs are formed, till, by successive additions, the primitive 
crust augments in size and thickness, for some time, varying 
from two days to seven. It is now of a conical form, on which 
the successive additions may be perceived; its colour is 
brownish-black, and its shape has been well compared to that 
of a small oyster-shell, if its superficies is greater than its 
height; when the contrary is the case, and it is more conical, 
it much resembles, as. is observed by Willan, a limpet, (pa- 
tella. J This incrustation often remains for a long time, and 
although in some cases it may be detached with ease, in others 
this is not accomplished without much difficulty. The ex- 
posed surface presents an ulceration of different degrees in 
extent and depth ; this latter is greatest when the scab has re- 
mained attached for some time. Sometimes a new scab is 
formed very promptly, but at others, an ulceration remains 
which is deep and of a bad character, healing with great dif- 
ficulty, particularly in aged persons. Its edges are of a livid 
red and swelled, the surface is unhealthy and bleeds on the 
slightest touch; its size is sometimes larger than a dollar. Af- 
ter some time, cicatrization takes place, but a purple spot re- 
mains, which lasts for a long period and disappears but slowly. 

3d. The third variety, Rupia escharotica, (Willan,) appears 
to be the same affection, as is described by other authors as 
Pemphigus gangrenosa. This disease affects only infants and 
young children, from their birth to the end of the first teeth- 
ing. A cachectic state, produced by imperfect feeding, ex- 
posure to the effects of cold or some internal disease, appear 
to be its predisposing causes. 

The loins, thighs, legs, neck, superior part of the breast, 
the abdomen and scrotum, are its most usual seats. It com- 
mences by livid spots, which are slightly prominent, and soon 
present considerable vesications. These augment and form 
large flat bullae of an irregular form. The fluid they contain 
thickens and assumes a blackish colour. They are surround- 



RUPIA. 133 

ed by violet red areola. They soon break and leave exten- 
sive and deep ulcerations, whose edges are red and inflamed, 
and covered with a fetid and ill-conditioned sanies. Fresh bul- 
lae are successively formed, and follow the same course. The 
child experiences violent pain, there is much fever and wake- 
fulness, and when the disease is extensive, death may fol- 
low in one or two weeks. If this should not be the case, ci- 
catrization takes place, but extremely slow. 

Diagnosis. — Pemphigus and ecthyma are most likely to 
be confounded with rupia. This however differs from the for- 
mer, from its bullae rarely containing a serous and transparent 
fluid, butusually a sanious liquid ; added to which, the form of the 
scab, which is thick, rugose, and surrounded from the first by 
an areola, and resembling somewhat the shell of an oyster or 
limpet, will generally suffice, with the nature of the consecu- 
tive ulceration to distinguish it from pemphigus. 

Ecthyma, as we have already said, offers much analogy to 
rupia; they are often met with at the same time, on the same 
individual, and side by side. The most simple variety of ru- 
pia does not resemble the pustules of ecthyma. This simi- 
litude only exists where the epidermis is distended by pus and 
forms a real bulla. We have seen several times at the Hospi- 
tal of St. Louis, a considerable eruption of pustules of ecthy- 
ma, almost confluent, and in several points the cuticle distend- 
ed to the size of a quarter of a dollar, forming true bullae, fill- 
ed with a purulent liquid, which in drying gave rise to the 
characteristic scabs of rupia. It is to be remarked that these 
scabs were only formed on the larger of these accidental vesi- 
cations. In admitting the great resemblance that exists in cer- 
tain cases between these two diseases, it must be observed, 
that the marked form of the scab, and the deep and obstinate 
ulcerations of rupia, establish a distinction, which, if not 
strong, is at least sufficient to render a separate description 
necessary. 

Prognosis. — Rupia is never a fatal disease, with the excep- 
tion of the escharotica; the age of the patient, the state of 
his strength, and the extent of the ulcerations, will serve as 

18 



134 BULLAR DISEASES. 

guides to establish a prognosis, as to the duration of the dis- 
ease. 

Treatment. — The treatment of rupia generally consists in 
restoring, by a proper diet, the broken constitution of the pa- 
tients; tepid alkaline baths where the cicatrization is tardy, or 
else lotions with honeyed or aromatic wine, and light cauteri- 
zations with lunar caustic, will suffice for simple cases of this 
disease. But in the large rounded ulcerations which so often 
succeed Rupia prominens, this treatment is ineffectual. Emol- 
lients, although they assuage the pain, do not diminish the sur- 
rounding inflammation or hasten the cicatrization; the same 
may be said of adhesive strips, so often useful in obstinate ul- 
cers. It hence becomes indispensable to change the condition 
of the diseased surface, and caustics are the best means to ful- 
fil this result. The ulcerated surface must be several times 
deeply cauterized with lunar caustic, or washed with nitric or 
hydrochloric acid, mixed with water; and in those cases, 
where, in spite of these modes of cauterizing, the healing pro- 
cess does not take place, it must be repeated with concentrat- 
ed acids, or what is better, with the acid nitrate of mercury 
dissolved in nitric acid. A remedy we have often seen suc- 
ceed with M. Biett, is an ointment of the proto, or even the 
deuto-ioduret of mercury, in the proportion of 9i. of the 
first and gr. xii. to xv. of the latter to the ounce of axunge. 

In all cases, repose and a horizontal posture are indispensa- 
bly necessary, if the disease, (as usually happens,) is seated in 
the legs. 

In Rupia escharolica, recourse must be had, to emollients, 
at least during the continuance of fever. The decoction of cin- 
chona, good wine, and tonics, so often prescribed in these cases, 
do not appear to be productive of any good, 



ORDER IV. 

PUSTULAR DISEASES, 
PUSTULJE. 

THE diseases arranged in this order are characterized hy 
the presence of small circumscribed tumours, formed by the 
effusion of a purulent fluid on the inflamed dermis, which ele- 
vates the cuticle. These small tumours have received the name 
of pustules. 

The cutaneous inflammations marked by the development 
of pustules are variola, vaccinia, ecthyma, impetigo, acne, 
mentagra, and porrigo. The close alliance which exists be- 
tween the vaccine and small-pox, the termination of the first 
by an evident suppuration, and the intensity of the local in- 
flammation, have induced us to place the description of it af- 
ter that of small-pox. As to varicella, which has latterly been 
classed among the pustules, we have already stated, when 
treating of it, the reasons that induced us to leave it among 
the vesicular diseases. 

Every part of the body may become the seat of pustules, 
but among these diseases there are some, as variola, and some- 
times ecthyma, that clevelope themselves at once on the 
whole surface of the body, others are partial, as vaccinia, 
impetigo, porrigo, &c. Although they may occupy large 
spaces, some are confined to particular seats, as porrigo, men- 
tagra, acne, and even vaccinia, which only appears on the 
spot to which the contagious cause has been applied. 

The course of the pustular affections is acute or chronic, but 
each pustule may separately run its course in from two days 
to a week. The essentially acute pustular eruptions are vari- 
ola and vaccinia; ecthyma is generally acute, but it may be- 
come chronic. The. duration of these diseases is from one to 
three weeks. 



136 PUSTULAR DISEASES. 

The chronic pustular diseases are porrigo, impetigo, and 
acne. Their duration is not certain, and is sometimes pro- 
longed for an indefinite period. They may also be acute, 
particularly impetigo. 

In these diseases the pustules present differences it is essen- 
tial to pay attention to; they are generally phlyzacious in the 
acute affections, and psydracious in the chronic. 

The phlyzacious pustules are larger, and, as their name in- 
dicates, have an inflamed base; the absence of this inflamma- 
tion characterizes the psydracious, which are smaller. 

Porrigo, as we shall mention, when treating of it, also 
presents two distinct species of pustules, the favi and achores. 

The form of the pustules is almost always umbilicate, in 
small-pox and vaccine, and sometimes in ecthyma. A ci- 
catrix of various degrees of distinctness is usually met with 
after variola or vaccinia. 

In the pustular inflammations, whose duration is indeter- 
minate, sometimes the pustules are irregularly scattered over 
the surface, and at others they are united in groups which of- 
tentimes have a marked form. The scabs that succeed to pus- 
tules offer characters which differ according to the nature of 
the disease, but they merit much attention. 

In Porrigo favosa, they are yellow, circular, and have a cen- 
tral depression, which lasts for a long time; when they have 
fallen off, they are not replaced until fresh favose pustules are 
formed. 

In impetigo the scabs which succeed to the pustules are 
thick, always rough, and are produced by the drying of a 
sero-purulent fluid, effused over the inflamed surface. They 
are of a greenish-yellow or brownish colour, and are replaced 
on their falling off, by similar crusts. 

The scabs that supervene on the pustules of mentagra and 
acne are less characteristic and last but a short time. In these 
two latter pustular phlegmasia?, a chronic inflammation may 
be often observed at the points where the pustules are deve- 
loped; this causes callosities of different sizes known under the 
name of tubercles. The chronic pustular eruptions, seldom 



PUSTULE. 137 

leave scars, but the skin in general preserves a red tinge for 
some time, which disappears but slowly. 

The pustular diseases may be complicated with each other, 
without one interfering with the march of the other. This re- 
mark applies equally to variola and vaccinia, although it has 
been said that these affections are never developed simultane- 
ously in the same individual. Other cutaneous inflammations, 
particularly the exanthematous and vesicular, are often com- 
bined with this class of eruptions. Variola is in many in- 
stances accompanied with different degrees of inflammation of 
some of the internal organs, but these complications are very 
rare in the other species. 

Causes. — Variola and vaccinia are only developed under 
the influence of contagion. Porrigo favosa and scutulata, al- 
though they may occur spontaneously, may be transmitted in 
certain cases by contagion. The other pustular eruptions are 
usually produced by some internal cause, which it is very dif- 
ficult to appreciate. 

Diagnosis. — The presence of small elevations filled with 
pus, will suffice to distinguish the pustular affections from 
other cutaneous diseases. Vesicles, it is true, may contain, at 
a certain stage of their development, a sero-purulent fluid, but 
this is consecutive to a transparent and serous liquid j whilst in 
the true pustular affections the pus usually is formed from the 
beginning; and besides, the physical characters of this pus, 
which is thick and yellow, distinguishes it without difficulty 
from the lactescent fluid contained in vesicles a short time be- 
fore their disappearance. There are no doubt, cases where the 
application of these rules is difficult, as for instance, in vac- 
cine, where a pustule arises after a perfect vesicle, but in ge- 
neral, the distinction is well marked. 

The copper-red colour of syphilitic pustules, with the other 
concomitant symptoms, will suffice to distinguish the ordi- 
nary pustular affections from those which originate from a ve- 
nereal cause. 

Prognosis. — With the exception of small-pox, the pustular 
eruptions, though often harassing, never end in death. The 



138 



PUSTULAR DISEASES 



prognosis is less favourable when the disease has existed for a 
length of time and a great number of remedies have been used 
without success. 

Treatment. — It is very difficult to lay down general rules 
for the treatment of these eruptions, when in a chronic state; 
though it should be strictly antiphlogistic when they are acute: 
sometimes this latter succeeds, but usually, recourse must be 
had to more energetic treatment in order to modify the parti- 
cular state of the skin. 

Variola. Small-Pox. 



Variola is a contagious eruption, characterized by phlyza- 
cious pustules, which are generally umbilicated, and whose de- 
velopment is preceded and accompanied by general symptoms 
of different degrees of intensity. 

Small-pox is divided into natural and inoculated, accord- 
ing as it results from an exposure to contagion, or from the 
introduction of this virus into the economy. It is also divided, 
from the relative number of its pustules, into distinct, or when 
they are scattered and disseminated over the surface of the 
body; and confluent when they are numerous, conglomerated, 
and as it were joined together. It is also termed coherent 
when the pustules, without being confluent, only touch at their 
edges. These last divisions, however, are very arbitrary, for 
the small-pox is often confluent in one place, on the face for 
example, whilst it is distinct in others. Besides, their exists 
between the slightest degree of distinct variola and the highest 
of the confluent, a host of intermediate varieties. 

This affection may also be divided into primitive and secon- 
dary, the violence of the latter being much less than that of 
the former. 

Sometimes variola, whether natural or inoculated, primitive 
or secondary, passes through regular stages; at others, on the 
contrary, its course is very irregular, its duration very short, 
and the disease, in fact, presents a very peculiar modification. 
This latter variety is only met with in persons who have been 



VARIOLA. 139 

vaccinated, or have already had the small-pox; it has been 
regarded by many physicians as a distinct disease from va- 
riola, and been described by them under the name of vario- 
loid, from its resemblance to this affection ; but later researches 
have corrected this error, and it is now acknowledged by all 
who have studied this subject, that the varioloid is only small- 
pox modified either by vaccination or a previous attack of 
small-pox. We shall first describe the true small-pox, and af- 
terwards treat of the modified or varioloid. 

The course of small-pox, whether distinct or confluent, may 
be divided into five stages, which are known under the names 
of incubation, invasion, eruption, suppuration, and desiccation. 
This division, founded on the most prominent symptoms that 
the disease presents, although it is an arbitrary one, still af- 
fords a facility in the study. 

The period of incubation comprises the interval of time 
that elapses from the infection to the beginning of the attack; 
its duration is from six to twenty days. It is not designated 
by an)r visible symptom, as the individual apparently conti- 
nues in good health. It has been remarked that the disease 
was most violent when this period was short. 

Invasion. — Distinct small-pox usually commences with 
slight chilliness, a feeling of general languor, lassitude, pains 
in the limbs, and particularly in the back and loins. At the 
same time, heat of skin, frequency of pulse, cephalalgia, vio- 
lent thirst, nausea, vomiting, and pains in the epigastrium, 
sometimes of a very marked character, make their appearance; 
the tongue is white, though often red at its point; finally, a 
state of depression exists, that is peculiar and striking. These 
symptoms last for three or four days, and often increase in 
violence, a cough and oppression supervene, the tongue be- 
comes of a vivid red, in adults there is a tendency to perspi- 
ration and sleep; drowsiness, coma, or even convulsions, in 
children, and a greater or less degree of frequency of the 
pulse; these symptoms diminish and cease when the eruption 
appears. 

In confluent small-pox the eruptive fever is generally vio- 



140 PUSTULAR DISEASES. 

lent, the heat of skin very great, and the thirst ardent; the 
tongue is dry, arid, and covered with a blackish coat, as are 
also the lips; the depression is very great, sometimes there is 
diarrhoea, but in general an obstinate constipation takes place. 
The eruption, which occurs towards the third or fourth day 
of the disease, first appears on the face, but in some rare cases 
on the hands, it then spreads over the neck, arms, and rest 
of the body, in about twenty-four hours. Sometimes it is 
preceded by an erythematous redness, and manifests itself by 
little red points, which resemble so many small papulae. When 
the eruption is very confluent on the face, this part is much 
injected, and the small red points are confluent from the be- 
ginning, but when it is distinct, it is easy to enumerate them 
both on the face and the other parts of the body. The erup- 
tion, as we have said, is terminated in about twenty-four hours; 
during this time the skin is hot and shining, there is often a 
marked exacerbation of the symptoms at the commencement, 
but they decline as the eruption appears. The period of erup- 
tion is separated from that of suppuration by an interval of 
four or five days; during this time the small red points aug- 
ment in size, and as they increase, each pustule presents a cen- 
tral depression or a peculiar kind of flatness. This augmenta- 
tion in size arises from the formation on each small inflamed 
spot of the dermis, of a whitish matter, which, though at first 
soft and of a lymph-like appearance, soon acquires a certain 
degree of consistence. This substance differs as much from 
pus, as it does from the whitish matter so often produced on 
blistered surfaces. On examining the skin on the second 
day of the eruption, a multitude of small elevations, having a 
red and inflamed base, will be seen. These elevations are 
rather vesicular than papular. But it is rare to find perfect 
vesicles, and, almost always, on opening them with the point 
of a lancet, there is no escape of serum, but it will be found 
that the cuticle is distended by a sort of semi-transparent, plas- 
tic lymph. At this period many of these pustules are acumi- 
nated, but others already present a central depression. On the 
third day of the eruption, this central depression is strongly 



VARIOLA. 141 

marked in most of the pustules, and even in those, that were 
at first pointed. 

The umbilicated form of the pustules becomes more and more 
distinct as they increase in size, and as the epoch of suppura- 
tion approaches. They are whitish and surrounded by a light 
red areola, which extends in size about this time. At this 
period, the pulse is full and regular; the tongue often presents 
a certain number of pustules on its surface; they may even be 
perceived in some instances on the pharynx; deglutition is 
then impeded, and there is usually a little cough. 

If the eruption is confluent, which often takes place on 
the face, when it is distinct on other parts of the body, 
the small papular points we have spoken of, unite and 
form a large, red, tumefied, and somewhat rugose surface. 
The face appears to be the seat of an extensive erysipelas, 
drowsiness takes place, and the pulsations of the carotid arte- 
ries are very evident. In these cases, the central depression 
is rarely seen on the pustules on the face, which, on the second 
or third day, is covered with a kind of subcuticular, whitish 
pellicle. This is identical with the effusion of the white matter 
in the distinct pustules. At the same time, the limbs are co- 
vered with white pustules, having the central depression, but 
they are less confluent on the body. The tongue is also stud- 
ded with pustules, and a severe angina indicates that the erup- 
tion also exists in the pharynx. The presence of these pus- 
tules on the eyelids produces a violent and painful ophthalmia. 
Finally, the symptoms of coryza and cough which exist in a 
majority of cases, announce that the eruption has reached the 
nasal fossae and the trachea. 

Suppuration occurs on the fifth or seventh day of the erup- 
tion, and terminates in two or three. It usually commences 
with a secondary fever of different degrees of intensity, ac- 
companied by a general swelling of the skin; this tumefaction 
is most strongly marked on the face and hands. In propor- 
tion as the pus is secreted, the cuticle is elevated, and the pus- 
tules lose their umbilicated form and become spherical, and at 
the same time, if they are situate at some distance from each 

19 



j 42 PUSTULAR DISEASES. 

other, the intervals become red, swell, and the patient expe- 
riences a sensation of tension and pain. Suppuration is gene- 
rally, first established on the face, and lastly on the hands and 
feet where the pustules also remain a much longer time un- 
broken, from the thickness of the cuticle. The pustules are 
ordinarily yellow, but in some cases present a blackish hue. 
If a mature pustule be opened, which had previously present- 
ed a well-marked central depression, a yellowish pus will be 
found, below which, is a small, white,umbilicated disk, perfect- 
ly resembling in form and size, the pustule before the pus had 
altered its shape. When the pustules have acquired their full 
development, they may remain stationary, for two or three 
days, particularly those situated on the extremities, but in ge- 
neral they soon break and are replaced by scabs. 

When the pustules are very confluent, they are usually 
small, and the development of each cannot be thus followed, 
particularly on the face. The subcuticular, whitish pellicle, 
which is formed on this part during the first days of the erup- 
tion, does not become covered, as in the distinct pustules, with 
a yellowish pus ; but towards the fifth or sixth day of the erup- 
tion, and whilst the face is swelling, the surface of the epider- 
mis becomes rough, and is soon covered with a scab which is 
at first thin and yellowish, but afterwards, as suppuration ad- 
vances, assumes a thick and brownish appearance. On the 
limbs, where the tumefaction is less marked, and the epider- 
mis more resisting, this membrane is often greatly distended 
by the pus, particularly when the pustules are very confluent. 
A greater or less degree of fever, tumefaction of the face 
and hands, and ptyalism are the usual phenomena accompany- 
ing suppuration, and are more strongly marked, as the pus- 
tules are more confluent. It must, however, be remarked, that 
these symptoms are not always in relation to the extent of the 
eruption, and that they are sometimes very slight where this 
is very abundant. The tumefaction of the face generally 
commences towards the fifth or sixth day of the eruption, con- 
jointly with the secondary fever. The eyelids, lips, and nose 
usually swell before the other parts, and that of the eyelids is 
sometimes so considerable, as to prevent vision for several days. 



VARIOLA. 143 

The swelling of the hands occurs about the same time as that 
of the face, and like it, diminishes towards the eleventh or 
twelfth day of the eruption, when the suppuration is terminat- 
ed. Ptyalism sometimes occurs at the time of the eruption, 
but is generally observed from three to seven days afterwards. 
In some cases, it is scarcely visible, even when the eruption 
is abundant; in others it is profuse, and constitutes one of the 
most harassing symptoms. The general symptoms, besides 
those of the secondary fever, that usually occur during the 
suppuration, are diarrhoea, oppression, and drowsiness; this 
epoch is also frequently complicated by others, of which we 
shall hereafter speak. 

Desiccation almost always begins on the face, and this part 
is often covered with scabs, when the pustules on the extre- 
mities have scarcely arrived at maturity. In distinct small- 
pox, sometimes the pustules break and form scabs, and at 
others, the cuticle becomes rugose, brownish, and the effused 
fluid in drying forms a crust of different thicknesses. 

When the disease is confluent, the scabs are often formed on 
the face on the eighth or ninth day. The features are then 
hidden by a thick, brown incrustation, which is detached from 
the fifth to the fifteenth day from its formation, and is re- 
placed by furfuraceous scales, which are often renewed. 

During this period, the patient exhales a peculiarly nauseous 
odour, and at the same time his sheets and linen are more or 
less imbued with the purulent matter that flows from the pus- 
tules. A violent itching accompanies the formation of the 
scabs, and induces the patient to scratch himself. Hence, we 
often observe that in children the face or skin is deeply exco- 
riated by the action of the nails. 

When the scabs are entirely detached, the surfaces they co- 
vered, will be found of a vivid red colour, which disappears 
but slowly, and, as this takes place, the cicatrices become more 
and more visible. These, which are always most numerous 
on the face, are not separate as in distinct small-pox, but are 
united and form seams, that traverse the face in all directions, 
wholly disfiguring the features, in the confluent variety. 



144 PUSTULAR DISEASES, 

Such is the usual course of this disease, but it is far from 
being regular in its march. The fever that precedes the erup- 
tion, is sometimes very severe, and accompanied with violent 
symptoms. The eruption, which usually appears on the se- 
cond or third day, may be retarded, and not occur until the 
fifth or sixth. These irregularities are most common in 
confluent variola, and where serious complications exist. 

The eruption may also present peculiar characters, as, for 
instance, in the variety termed chrystalline, where, instead 
of pustules, small phlyctenae filled with serum are to be found. 
In these cases the disease is generally very severe. 

When this affection is the result of inoculation, it is usually 
very mild. This process is performed by making slight punc- 
tures or excoriations in the skin, with the point of a lancet 
charged with the variolous virus; the other modes, as frictions, 
setons, blisters, &c. have been abandoned. Towards the third 
day a slight redness is perceived around the inoculated spot. 
At this time, and especially on the fourth day, a small circum- 
scribed tumour is to be felt, on passing the finger over this spot. 
The redness is greater on the fifth day, and on the sixth the cuti- 
cle is found elevated by a fluid, at the same time a central de- 
pression is visible. On the seventh day, symptoms of irrita- 
tion of the lymphatic vessels surrounding the puncture may 
be perceived, the motions of the arm become painful, and be- 
fore the tenth, general symptoms of infection are developed, 
analogous to those of the invasion of natural small-pox. In 
some rare cases, inoculation may occasion general symptoms 
without giving rise to a local eruption, and sometimes this is 
not visible for eight, ten, or fifteen days after the operation. 

The general symptoms are those of small-pox, and, although 
they may be severe, they are generally very mild. The erup- 
tion that succeeds them, is in most cases very slight, but may 
also become confluent, or even in some instances be wholly 
wanting. The local eruption begins to dry about the twelfth 
or fifteenth day from the inoculation. The scab which is 
formed, falls off towards the twentieth or twenty-fifth day, 
leaving an indelible scar. 



VARIOLA. 145 

The distinct, but above all the confluent small-pox, may be 
accompanied by a multitude of anomalous symptoms. 

The invasion is sometimes announced by unpleasant pheno- 
mena. The chills are very violent, the heat of a burning 
character, whilst, at the same time, the head-ache and pain 
in the epigastrium are extremely severe. The nausea and 
vomiting may be obstinate. Sometimes violent pains in the 
loins, limbs, and sides, resembling nephritis, rheumatism, or 
pleuritis, make their appearance. In some instances, a pro- 
found lethargy or violent delirium,, convulsions, or even death, 
may occur before the appearance of the eruption. 

Among the symptoms which may accompany the eruption, 
may be enumerated, sanguineous congestions in the different 
organs, or haemorrhages, as epistaxis, haemoptysis, &c. When 
the congestion occurs in the internal organs, the nature of the 
symptoms depend on the viscus affected. Congestion of the 
brain and its membranes, is indicated by subsultus tendi- 
num, convulsions, lethargy, coma, or apoplexy. At other 
times, it takes place in the thoracic viscera, inducing diffuse 
pulmonary apoplexy, pneumonia, pleuritis, and suppurative 
catarrh, which Laennec justly considers as an acute oedema of 
the lungs; in one case of this kind we have seen the subcre- 
pitating rattle of oedema mistaken for the crepitating sound of 
pneumonia, so as to induce a belief in the presence of that dis- 
ease. Sometimes the tissue of the skin becomes the seat of the 
congestion, this is easily known by the existence of petechia?. 
Finally, ophthalmias are very common at this stage, Croup 
is happily but a rare accompaniament. 

The period of suppuration is that in which death generally 
occurs; but in such cases the suppuration is seldom freely es- 
tablished. The symptoms occur at this time with frightful ra- 
pidity, and death may take place in a few hours, or even in a 
few minutes, without our being able to assign a cause for this 
fatal event. It has lately been attempted to be explained by 
the rupture of the pustules in the trachea, which causes as- 
phyxia, and rapidly induces death. Salivation may become 
very troublesome at this epoch, and be accompanied with 



146 PUSTULAR DISEASES, 

cough, and a greater or less degree of difficulty in deglutition. 
Diarrhoea, which often occurs at this time, particularly in 
children, is far from being a bad sign, at least, if it is not 
profuse. 

During the period of desquamation, much fewer alarming 
symptoms occur than in the preceding stages. Eruptions of 
ecthymatous pustules, or small subcutaneous phlegmonous 
tumours, in considerable numbers, may arise at this time. In 
some cases, rupia may take place on the lower extremities, fol- 
lowed by obstinate ulcerations. 

Finally, a slow fever, and symptoms of gastric and gastro- 
intestinal irritation, bronchitis, catarrh, chronic ophthalmia, 
deafness, and blindness, may all supervene on variola; the 
development of pulmonary tubercles also appears to be has- 
tened in certain cases by this disease. 

The causes of these complications, are not always easy to 
understand, they are met with in the robust, and in those 
whose constitution is injured, either by age, excess, or inter- 
nal diseases. They are above all, to be dreaded in the heat of 
summer, or the middle of winter. Fear, mental affections, 
the sight in a looking-glass, of the hideously disfigured face, 
have all occasioned sudden and fatal consequences. 

Dissection. — The pathological lesions generally observed 
in individuals who have died from variola, are sanguineous 
congestions in the encephalic and thoracic organs. Variolous 
pustules are often met with in the mouth, on the pharynx, 
oesophagus, and even in the larynx and trachea; the stomach 
and intestines are rarely affected, with the exception of the 
mucous membrane of the rectum. Care must be taken, not to 
confound variolous pustules with a morbid enlargement of the 
follicles of the mucous membrane of the intestines. The cen- 
tral orifice in these follicles give them, when thus swelled, 
somewhat of a resemblance to the umbilicated form of the 
variolous pustules. These pustules on the mucous coat of the 
intestines are more especially to be met with in persons who 
have died before suppuration was well established. At a later 
period, the epithelium detaches itself, leaving only small. 



VARIOLA. 147 

red, circular patches, which are not elevated in the centre. 
We have never observed in any of the bodies of persons who 
have died from small-pox, that we have had occasion to exa- 
mine, any pustules on the mucous membranes that were dis- 
tended with pus; it appears to us that the extreme thinness of the 
epithelium, particularly in the larynx and trachea, from its early 
rupture, prevents an accumulation of pus from taking place. 
We do not insist on this point, as it has been advanced, that the 
sudden and fatal termination of small-pox during suppuration 
often depended on the rupture of pustules situated either in the 
larynx, the trachea, or bronchia. * The gastro-intestinal mucous 
membrane, with the exception of the lower part of the rec- 
tum never presents any variolous pustules. The internal sur- 
face of the stomach often appears dotted with red points, but 
that of the intestines is rarely injected. The heart is generally 
flaccid and filled with black blood ; the lungs are often gorged 
with this fluid. The redness of the internal surface of the aorta 
is far from being a constant appearance, as has been advanced by 
some late authors. 

On the skin, pustules are found in various numbers, and in 
examining their anatomical structure, particularly before the 
pus, by distending the cuticle, has destroyed their umbilicated 
form, the following peculiarities will be observed: — 

1st. The cuticle preserves its natural thickness, and is easily 
detached, leaving exposed a whitish and smooth surface, ele- 
vated at the edges, and depressed in the centre. 

2nd. A small umbilicated disk of various thicknesses, form- 
ed by a whitish substance, having a certain consistency, and 
which appears to be a real exudation from the inflamed der- 
mis. This substance occupies the place of the mucous coat, 

* Dr. Rennes, physician to the Military Hospital of Strasburg, is of opi- 
nion that most patients who fall victims to this disease from the tenth to 
the fifteenth day, perish, from asphyxia rather than inflammation of the re- 
spiratory organs. To corroborate his assertion, he gives the result of the 
examination of four bodies of persons that died in this manner in confluent 
small-pox, in which the nostrils, pharynx, and sometimes the larynx and 
Lrachea were covered with thick layers of a tenacious mucus. — Trass. 



148 PUSTULAR DISEASES. 

and at first appears to be continuous with the layer which is 
immediately under the epidermis, but afterwards is easily se- 
parated from it. This small body adheres to the dermis by its 
centre, where it is also much thinner, and often tears when it 
is attempted to be raised. Whatever may be the primary 
cause of the umbilicated form of the pustule, it is evident that 
this substance preserves it even when the cuticle is elevated by 
pus; if at this period it be examined with a little care, it will 
be found, as we have above said, at the bottom of the pus- 
tule, still presenting the form and size that the latter possessed, 
before the cuticle had been detached by suppuration. The 
varieties that this substance presents, in form, thickness, &c. 
probably depend on the greater or less violence of the inflam- 
mation of the spot, where it is developed. Although it is usu- 
ally found in the pustules, there are cases where it does not ex- 
ist, but in such instances the pustule is very rarely umbilicated. 

3d. Finally, below this small disk, the dermis is found of a red 
colour, sometimes covered with purulent matter. When the 
pustules are examined at a more advanced stage, there is 
always a quantity of thick, yellow pus to be seen. * 

Causes. — Variola depends on an unknown contagious prin- 
ciple, which is communicable either mediately or by contact, 
and may be transmitted a certain distance by means of the 
wind. No sex or age, without even excepting the foetus, is 
exempt from this affection, which appears in all seasons and 
in all climates. Although sometimes sporadic, it generally 
reigns as an epidemic, and in such case, exercises its ravages 
more particularly in the summer and autumn. 

* Mr. Deslandes, in a paper on the nature of the pustules in small-pox, dif- 
fers somewhat from our text. He says that the depressions visible on the 
skin when beginning to swell, are owing to attachment of the secretory ducts. 
That this is the cause of the central depression in the pustules of small-pox. 
Each pustule has for its base one or more of these ducts. The pustules are 
either infiltrated or they are true abscesses. The former are flat, and are much 
deeper than the latter; they are also more dangerous, and particularly affect 
the face. That there is sloughing in almost every pustule, and that the 
large scabs that frequently separate from the face, are real sloughs of the 
surface of the cutis. — Revue Med. — Trans. 



VARIOLA. 149 

The contagious principle developed by variola, is far from 
exerting the same influence on all individuals; thus we see some 
persons, who are unaffected by it, even under circumstances 
the most favourable to its action, but these cases are rare, and 
these individuals generally contract the disease at another time 
of their life. In general, this contagion affects a person but 
once, but it is proved in the most incontestible manner by a 
multitude of facts, that it may not only attack the same indi- 
vidual a second time, but also, that the eruption may be very 
violent. We find in authors, and more particularly in the 
work of Thomson, a multitude of curious and well-authenti- 
cated cases, which prove most positively that the variolous virus 
may develope more than once, a decided eruption in the 
same individual. Among these, is that of a lady, who had 
the small-pox in her childhood, and who afterwards became 
the mother of six children, and was six different times attack- 
ed with this disease, contracted from suckling her children, 
whilst they were under the influence of inoculation. Each 
time, the eruptive fever and eruption were slight, but the 
course of the pustules was that of variola, and the cause of the 
attack was evidently the inoculated small-pox under which 
the children were labouring. 

From these, and from several other well-authenticated facts 
of the same kind, which came under our notice in the epide- 
mic of 1825, we have been much surprised to see advanced in 
a work recently published on diseases of the skin, " that va- 
riola never affects the same individual more than once, and it 
is permitted to doubt the cases of secondary attacks reported 
either by authors, or more recently by physicians, who do 
not appear to have made a close study of the varieties of vari- 
cella." We are the more astonished at this opinion, as the 
author himself regards varicella, which, with Mr. Cross and 
some other writers, he divides into pustular varicella, (vario- 
loid,) and vesicular varicella; as a variety, or modification of 
variola, resulting from the feeble action of the variolous virus 
on the system. But in these cases, one of two things must 
take place; either the variolous virus can develope a new dis- 

20 



150 TUSTULAR DISEASES. 

ease, an affection sui generis, distinct from small-pox, or the 
same disease is again produced, but with much milder symp- 
toms. If we admit the latter opinion, and the author does so, 
in regarding varicella as a modification of variola, it is at least 
advancing a singular hypothesis to deny the variolous nature 
of the disease, by saying it is only varicella. 

When the specific cause of small-pox exerts its influence on 
vaccinated persons, it generally developes a disease which 
presents some peculiar characters, and has been designated of 
late years, under the name of varioloid. This variety of small- 
pox is not confined to the vaccinated, but is also observed 
in those who have already had the small-pox; but it is to be 
remarked that this disease is more generally modified when it 
appears after vaccination, than when it occurs after small-pox. 
We have here another proof that the anti-variolous power of 
the vaccine is greater than that of small-pox itself. 

As there has latterly been much discussion on the modified 
small-pox or varioloid, it appears right that we should enter 
into some details on this subject. This variety only differs 
from ordinary small-pox by the extreme irregularity and ra- 
pidity of its progress, by its mildness in the generality of 
cases, and finally, by its usually terminating favourably. It is 
above all, the irregularity and rapidity of its course, joined to 
the absence of all secondary fever, that characterizes this va- 
riety, which nevertheless may sometimes be a more severe 
disease than common distinct small-pox; in this latter case, 
the pustules, although not numerous, go through the usual 
stages of variola, which never takes place in varioloid. 

The time that has elapsed since the epoch of vaccination or 
of a former small-pox, does not appear to modify the course of 
the varioloid in any respect. It may be seen, in fact, occur- 
ring with violence in persons who have been successfully vac- 
cinated only a few weeks before, and constituting a very slight 
disease twenty years after this process; and the same thing 
takes place with regard to variolation. 

The same person may be affected several times with this 
disease, on being exposed to the variolous contagion. Matter 



VARIOLA. 151 

taken from the pustules of modified small-pox, may develope 
the ordinary small-pox in its various forms in persons who 
have never had this disease, or who have never been vacci- 
nated; but generally, the disease thus communicated is very 
light, and in a great number of cases the inoculation is not 
followed by any sign of general infection. 

In this variety, the precursory symptoms of the eruption 
may scarcely appear; they are in other cases very violent and 
alarming, without the succeeding eruption being extensive. 
Thus, after much fever, accompanied with excitement and vio- 
lent delirium, a very slight eruption of small pustules, whose 
number varies from one to twenty, may make its appearance, 
and is followed by a complete cessation of all the alarming 
symptoms; they dry up in four or five days, so that it is 
scarcely necessary for the patient to keep his bed. The du- 
ration of the precursory symptoms is two or three days or 
even more. 

The eruption may be preceded by slight erythematous red 
spots on different parts of the body. Sometimes, as we have 
said, there are scarcely any pustules, at others from twenty to 
one hundred may be counted on different parts of the body ; 
but in certain cases the eruption is much more violent, and 
may cover almost the whole of the body. 

The eruption generally commences on the face, but may 
frequently be simultaneously developed on different parts of 
the body; sometimes it begins on the limbs, and very often 
appears in a successive manner. Small red points are first to 
be observed, which form red, hard, and elevated papulae, but 
which do not all follow the same course. A greater or less 
number disappear without being transformed either into vesi- 
cles or pustules, others become vesicular and pustular in 
twenty -four hours, and that on the same individual. The ve- 
sicles are small, pointed, and filled with a milky fluid; they 
are often changed into umbilicated pustules, but in general 
they break or dry up in two or three days, and are replaced 
by thin, round scales, which adhere but slightly. Sometimes 
a red areola surrounds these vesicles, and gives them a cer- 



152 PUSTULAR DISEASES. 

tain resemblance to those of vaccinia. The pustules are often 
formed in twenty-four hours, but sometimes their march is 
slower. They are small and rounded, but never attain the 
size of those of ordinary small-pox, even when they appear in 
great numbers and are most distinct. These pustules are ne- 
ver distended with pus; they are soft and flaccid to the touch; 
and seem to have been suddenly checked in their progress. 
Sometimes they are acuminated, and sometimes depressed 
in their centre; in the space of from one to four days, the 
fluid they contain is absorbed, and there are formed either 
thin, flat, rounded, brownish scales, which soon fall off, or small 
brown scabs, which are hard and shining, and as it were glued 
to the skin, which sometimes last to the twentieth day. It is 
evident, from the irregular march of the eruption, that there 
may be found at the same time, on the same individual, pa- 
pular elevations, vesicles, pustules, scales, or scabs. This phe- 
nomenon is more remarkable when successive eruptions occur 
during several days. In some cases, after the detachment of 
the scales, they are replaced, above all on the face, by eleva- 
tions in the form of warts, which disappear but slowly, and 
by successive desquamations. When the eruption is confluent, 
as is sometimes observed on the face, small, yellow, lamellar 
scabs may be formed, but even in these cases the secondary 
fever is scarcely perceptible. 

The duration of the disease, which sometimes scarcely me- 
rits this name, is from six to twelve days at the most. The 
termination is generally favourable, though sometimes slight 
scars may be left on the face or elsewhere. 

Diagnosis. — The diagnosis of variola would appear to be 
very easy; the presence of pustules, generally umbilicated, 
whose appearance is preceded by fever and other general 
symptoms, joined to the peculiar stages of this eruption, will 
suffice in the generality of cases, to distinguish the small-pox, 
not only from other pustular affections, but also from all other 
cutaneous diseases. Varicella is the only eruption which re- 
sembles small-pox, and notwithstanding the diagnostic rules 
which have been established to distinguish them, there still 



VARIOLA. 153 

are cases where physicians of equal experience, are far from 
being of the same opinion, the one calling it variola, and the 
other insisting that it is varicella. 

Distinct small-pox, and above all, varioloid, have been con- 
founded with varicella, but it must be acknowledged, that 
cases exist where the diagnosis is very difficult, and there are 
also a great number, where the opinion is formed on precon- 
ceived ideas. It is in cases of secondary small-pox, that the 
physician who does not admit the possibility of a second infec- 
tion, or who avers that the small-pox can never be developed 
after inoculation, will deny the identity of the disease, by call- 
ing it varicella. From the same cause they give the name 
of varicella to the modified small-pox that makes its appear- 
ance in vaccinated persons, advancing as an unanswerable ar- 
gument, that the small-pox is never developed after vaccination. 

In comparing the march of the modified small-pox, with 
that of varicella, we find, it is true, that it resembles that dis- 
ease in many points of view, and it is certain that the name of 
petite verole volant e, or that of chicken-pox, have been equally 
applied to it in a great number of cases. In treating of vari- 
cella, we have spoken at length, (without prejudging their ex- 
actness,) of characters laid down by certain authors, as ade- 
quate to distinguish that affection, both from ordinary small- 
pox and its modifications. We again repeat, that we have found 
them fully sufficient to induce us to separate these diseases. 

The diagnosis of the different diseases which may be com- 
plicated with small-pox, may be involved in much obscurity. 
The rapidity of their progress is oftentimes so great, that it 
scarcely gives the physician an opportunity of acting, before 
a mortal congestion takes place in one of the vital organs, and 
the patient perishes without even a development of the usual 
inflammatory symptoms. Coma, delirium, excitement, or 
convulsions, announce, that in these cases there is a greater or 
less degree of irritation in the brain. In some attacks of the 
suffocating catarrh, the subcrepitating rattle of oedema may, as 
we have already said, be mistaken for the crepitating sound of 
pneumonia. 



154 PUSTULAR DISEASES. 

Prognosis. — The prognosis of variola is favourable, when 
the eruption is light, and its progress regular; but in general, 
we should be cautious in our prognosis of confluent small-pox, 
for symptoms are often developed with astonishing quickness, 
and carry off patients in a very short time, where there was 
nothing to indicate so fatal a result. The prognosis is bad, 
when the disease appears in children during dentition, in ple- 
thoric and robust adults, in persons weakened and enfeebled 
by age, previous disease, or excesses. It is also unfavourable, 
when it occurs in pregnant women, or in those who have been 
recently delivered, as well as the young and beautiful, who 
necessarily dread a disease so fatal to beauty. 

The violence of the precursory symptoms is to be particu- 
larly dreaded, when they remain after the eruption has ap- 
peared, and the sudden retrocession of this last is always dan- 
gerous. The prognosis may also be based on the nature of 
the eruption; thus, when it is abundant and intermingled with 
petechias, or when the pustules are filled with blood, it is al- 
ways dangerous. It is the same, when the eruption does not 
advance, and the pustules remain white and flattened. But, 
even in these cases, an unfavourable opinion must not be ex- 
pressed, merely from the appearance of the eruption, a scru- 
pulous attention must be paid to the general symptoms. The 
encephalic and thoracic organs above all must be closely 
watched. 

Treatment. — When small-pox, whether distinct or conflu- 
ent, pursues a regular course, without being accompanied by 
symptoms of inflammation of some of the vital organs, the 
treatment is to be very simple; confinement to bed, a mode- 
rate temperature, regimen, and diluents, are all that are requi- 
site. Emetics are generally useless; if constipation continues 
too long, it may be obviated by simple or slightly laxative in- 
jections. Warm pediluviums, or the application of warm ca- 
taplasms to the feet, when the head is affected; soothing gar- 
gles if the angina is troublesome, emollient lotions on the eye- 
lids, when the pustules on them, produce great irritation, may 
also be employed with advantage in cases of simple small-pox. 



VARIOLA. 155 

When the eruption is tardy in its appearance, and this does 
not result from inflammation of some of the internal organs, 
an emetic and diaphoretics may be given, as the acetate of am- 
monia, or the patient may take a tepid bath, or what is pre- 
ferable, one of vapour. 

Very often small-pox, instead of passing through its stages 
in a regular manner, presents, as we have said, various com- 
plications which demand an active treatment. We will now 
review these remedies and the cases to which they are 
suited. 

Blood-letting has been advised, and employed at all times 
in the treatment of small-pox: but its use has been denied by 
certain writers, who, considering this disease as an affection 
wholly different from other inflammations, think that instead 
of being advantageous, it may be highly prejudicial. Expe- 
rience has proved, that unfortunately it is but too true, that 
in many cases, blood-letting will not prevent fatal results, but 
it has not been demonstrated that this termination was the ef- 
fect of its use, and in fact, in those cases where the eruption 
was attempted to be hastened by the use of successive bleed- 
ings, if this result has not been obtained, the disease has not 
been aggravated. There can be no doubt, but that this remedy 
is prejudicial, if we wait till congestions take place before 
making use of it, or till nature has been overwhelmed by the 
violence of the disease, in such cases, bleeding will certainly 
hasten death. 

During the period of invasion, when there is much fever, 
and the symptoms of gastro-intestinal or cerebral irritation are 
of a high grade, general or local bleedings may be employed 
with great advantage. The local detractions of blood should 
be made from the epigastrium or anus, from the neck, tem- 
ples, or mastoid apophyses, according to the nature of the 
symptoms. When violent local pains exists, there need be 
no hesitation in applying leeches to the part. 

When the eruption is very confluent on the face, and there 
is lethargy or violent angina, one or two applications of leeches 
to the mastoid apophyses, or front of the neck, will produce 



156 PUSTULAR DISEASES. 

much relief. General bleeding is particularly indicated in ro- 
bust and vigorous adults, when the eruption is confluent; it is 
still more necessary when symptoms of inflammation of the 
vital organs are developed during the progress of the eruption. 
But bleeding does not appear to be so advantageous at the pe- 
riod of suppuration, when the strength of the patient is already 
exhausted by the flow of pus, by the previous treatment, the 
fever, &c. &c. Congestions in the different organs often take 
place slowly, and the course of the symptoms is then very in- 
sidious. There is supineness and depression, the eruption 
does not advance, the pulse becomes weak, there is slight de- 
lirium during the night, and the patient sinks before sup- 
puration has been established. In these cases, blisters to the 
lower extremities, and purgatives, at least if the symptoms of 
gastro-intestinal irritation do not forbid them, are more useful 
than blood-letting, but there should be no hesitation in prac- 
tising local detractions of blood, if there appears to be a ne- 
cessity. 

The utility of bleeding, in those cases where symptoms 
speedily terminating in death make their appearance, appears 
to be very great, if we reflect that an examination of the bo- 
dies after death usually reveals to us sanguineous congestions 
in vital organs, and particularly in the brain and lungs. But 
experience has not demonstrated that the advantages of this 
remedy are as great as the theory seems to promise; neverthe- 
less, these means, with laxatives, offer the greatest chance of 
success. It is no doubt, very easy to lay down rules, but it is 
often extremely difficult to apply them at the bed-side of a 
patient, for if, on the one side, it is essential to employ as soon 
as possible the remedies we have spoken of, on the other, it is 
very difficult to distinguish the premonitory symptoms of these 
anomalies, from those which usually accompany and sponta- 
neously disappear with the eruption. In all cases it should be 
borne in mind, that bleeding is far from acting as efficaciously 
in inflammations accompanying variola, as when they occur 
by themselves. 

Mild purgatives are often very useful at the period of the 



VARIOLA. 157 

suppuration, when congestion exists either in the brain or in 
the thoracic viscera, which is announced by coma or con- 
vulsions, or by a greater or less degree of difficulty in the res- 
piration. It is perhaps, needless to add, that purgatives should 
not be used where there are marked symptoms of gastroin- 
testinal irritation. The best are castor oil, senna, jalap, calo- 
mel; or the milder kinds, as tamarinds, and cremor tartar. 
Mild laxatives, the application of a few leeches below the 
lower jaw, and soothing gargles, are very useful when the sa- 
livation is profuse. 

Some physicians, in the hopes of hastening the eruption, 
have advised that the body should be violently rubbed with a 
coarse cloth, a short time after the appearance of the pustules, 
others recommend that the pustules on the face should be cau- 
terized, either one by one, or in mass, with the nitrate of sil- 
ver, to avoid cerebral congestions, and to prevent the face from 
being deformed by scars. These advantages are more imagi- 
nary than real, and results have even been obtained, which were 
absolutely contrary to the intended effect. The best mode of 
preventing cicatrices on the face, consists in opening each pus- 
tule with great care, evacuating the pus, and by emollient fo- 
mentations preventing a long adherence of the scabs. But, it 
may be readily supposed, that this cannot be done when the 
eruption is very confluent, and it is in such cases that disfigur- 
ing scars are most to be apprehended. The only thing to be 
done is to hasten the disengagement of the scabs. 

Ablutions with cold water on the body, during and after 
the eruption, should never be employed. They may be use- 
ful in measles and scarlatina, when the skin is dry and arid, 
and the heat extreme, but in this disease there is a peculiar 
operation going on in the skin, which it appears to us should 
not be interrupted. 

Emetics and the acetate of ammonia may be used with ad- 
vantage, when the eruption is tardy in its appearance, and, 
combined with blisters, sinapisms, and warm baths, they may 
be very useful, where from an exposure to cold, (as happens in 
the winter,) the eruption recedes or does not pursue its regu- 

21 



158 PUSTULAR DISEASES. 

lar course, and where there exists at the same time, languor, 
general weakness, and a small, chorded pulse. 

Tonics, such as w^ine, cinchona, camphor, &c. which have 
been advised in cases where the strength appears to fail, 
should be rarely used. They may be advantageous, where, 
at the period of suppuration, the patients remain in a state of 
prostration, but their employment requires much judgment; 
they should never be resorted to, where the only indications 
are dryness of the tongue, depression, and weakness. 

The opiates are very useful, in cases of obstinate watchful- 
ness, or profuse diarrhoea without much fever. 

Towards the close of the disease, tepid baths, given with 
precaution, will favour the desquamation, and may diminish 
the tendency to the formation of boils, subcutaneous abscesses, 
or even of the pustules of ecthyma, &c. 

Laxatives should not be used at this time, without some po- 
sitive indication; it is true that this disease is followed by a 
peculiar state of the digestive organs, with loss of appetite, &c. 
but these symptoms will disappear under the use of mild ape- 
rients. 

The symptoms that may arise as sequelae on small-pox, each 
demand a particular treatment, but it is impossible to enter 
into the details in this place. 

Vaccinia. Cow-pox. 

Vaccinia is a contagious disease, which sometimes exists na- 
turally on the udders of cows, or transmitted by inoculation 
from individual to individual, in order to prevent, or at least 
modify the small-pox; is characterized by one or more silvery, 
large, flat, multilocular pustules, depressed in the centre, sur- 
rounded by an erythematous areola, and giving rise to a brown- 
ish scab, which detaches itself about the twenty-fifth day, leav- 
ing a characteristic scar. 

Vaccine is rather a vesicular than a pustular affection, but 
we have thought ourselves excusable in placing it immediately 
after small-pox, from the intimate relations that exist between 
these diseases. 






VACCINIA. 159 

Causes. — Vaccine often occurs in girls and children who 
have the care of cows, whose udder may present this erup- 
tion, known in England under the name of cow-pox, and it 
was the happy privilege that these individuals enjoyed of being 
exempt from the attacks of small-pox, when it was prevalent 
around them, that led Jenner to the discovery of this inesti- 
mable benefit. 

A true vaccinia sometimes appears on the hands of grooms 
who have the care of horses affected with the grease. We 
have seen two cases of this kind in the Hospital of St. Louis, 
in which the characters presented a perfect identity with those 
of cow-pox. In the latter case, the anti-variolous power ap- 
pears to be less marked, but it will require more numerous 
observations to determine any thing positive on this head.* 

Inoculation with the vaccine virus is the most usual cause 
of this eruption. This virus may be taken either from the cow 
or from a pock induced by vaccination; this last method has 
been preferred, as it is milder, occasions fewer accidents, and 
is quite as efficacious. 

The vaccine matter, either for immediate use, or for pre- 
servation, should be taken on the fourth or fifth day, dating 
from the development of the pustule, or the eighth or ninth 
day of the eruption. 

Three modes have been proposed for immediate vaccination, 
from arm to arm, which is the most frequently used, as well 
as the surest. That by puncture is much preferable to those 
made by a blister or by an incision. These two last are in fact 
much less certain; the first, from the violent irritation it induces, 
and the latter from the flow of blood it occasions. Hence, the 
puncture should always be had recourse to. It may be practised 
on every part of the body, but the usual spot selected is about the 

* It is found by experience that vaccine will originate in cows that feed in 
pastures where there are no horses, so that the opinion which ascribes 
the origin to the affection of horses termed the grease, must be erroneous. 
Viborg, however, found that he could produce vesicles on the udder of the 
cow, by inoculation with the matter of grease, not only in the original place 
of insertion, but also around it.— Ferussac. Bull,— Traks. 



160 PUSTULAR DISEASES. 

lower insertion of the deltoid muscle. Vaccination may be 
practised at any age, but is generally performed on infants, 
though it should not be done where they are under six weeks old, 
except from an urgent necessity. The operator, provided with 
a needle, or what is better, a lancet, the point of which is 
charged with a drop of the vaccine virus, is to seize with his 
left hand the posterior part of the arm of the individual to be 
vaccinated, so as to stretch the skin, and with the other he is 
to introduce his instrument horizontally a few lines. The in- 
strument is to be retained in the puncture a few moments, and 
pressed slightly so as to disengage the virus. It is advantage- 
ous to make several punctures, though only with the aim of 
augmenting the chances of the success of the operation, as a 
single vaccine vesicle, if properly developed, will as com- 
pletely protect the constitution from the variolous contagion 
as three or four.* 

Sometimes a peculiar idiosyncrasy in the individual will pre- 

* Dr. Gregory gives the following' directions for vaccinating 1 : — " Select 
from a healthy child, lymph of the sixth, seventh, or eighth day. Be careful 
that your lancet be extremely sharp, and if it be broad-shouldered, so much 
the better. Let there be a tangible drop at the end of the lancet, and be not 
satisfied with a mere moistening of the instrument. Let the skin be kept 
perfectly tense during the time of insertion, by grasping the arm of the child 
firmly, and extending the skin between the thumb and forefinger. Let the 
lancet be inserted from above downwards, and at each fresh insertion dip 
the point of the lancet in the lymph that remains around the puncture first 
made. Make from six to ten punctures in a circular form, enclosing a space 
about the size of a shilling. At each insertion, press the point of the lancet 
firmly against the lower surface of the wound." — Lond. Mid. and Phys. 
Journ. 

In the United States, the dry scab is generally used, and with apparently 
as much success as attends the various modes practised in Europe. It has 
the great advantage of keeping longer in an active state than lancets or 
threads charged with the lymph: Dr. Gregory says the former can be pre- 
served about six hours in summer by using great precaution. "We have 
successfully vaccinated with a portion of a scab ten months after it had been 
taken from the arm. All that is required is to crush a minute portion of it 
between two pieces of glass, and moisten it with a little water. See an inte- 
resting paper on this subject by Dr. Condie, in the North American Medical 
and Surgical Journal, Vol. IV. p. 14. — Tra^s. 



VACCINIA. 



161 



vent the action of the vaccine matter, and in some rare cases it 
is only developed after several successive operations. A pre- 
vious small-pox or vaccination, the inflammation of certain 
organs, an acute exanthematous eruption, a flow of blood from 
the puncture will all oppose the proper progress of the vac- 
cine disease. 

The method by incisions should only be used where you 
have threads imbued with the virus, as it is necessary to leave 
them between the lips of the wound. 

Symptoms.— The, progress of the vaccination may be di- 
vided into four periods. 

1st. In the first, which lasts three or four days, the puncture 
does not offer any particular change, the slight redness that 
surrounds it at the commencement, is common to all wounds 
of this kind. This may sometimes be prolonged to fifteen, 
twenty, or twenty-five days. 

2d. In the second, which commences towards the third or 
fourth day, and finishes about the eighth or ninth, there is 
first perceived a slight hardness, surrounded by some redness. 
This erythematous point becomes elevated, and on the fifth 
day, the cuticle is slightly raised by a serous effusion. An 
umbilicated vesicle now exists, which is still more manifest on 
the sixth day. Its colour is a dull white, and its form is round 
or even oval. It gradually augments in size, and preserves 
its central depression till the end of the eighth or ninth day, 
when the surface becomes flattened, and sometimes more 
elevated at the centre than the circumference; this is round, 
shining, and tense, is somewhat larger than the base of the 
vesicle, and contains a transparent, almost limpid fluid, en- 
closed in several cellules. It is at this time that the virus 
should be taken. 

3d. The third period commences on the eighth or ninth 
day, the vesicle has then acquired its full development, and is 
surrounded by a circumscribed areola of a vivid red, the dia- 
meter, of which, varies from three or four lines to two inches; 
it is accompanied by a marked tumefaction of the skin and sub- 
cutaneous cellular tissue. This erythematous surface often 



162 PUSTULAR DISEASES. 

becomes the seat of small vesicles. The symptoms are most 
prominent on the tenth day; the patient complains of heat and 
itching; the arm feels heavy; sometaes there is an engorge- 
ment of the axillary ganglions, the pulse is often accelerated, 
and sometimes a rosaceous or erythematous eruption, which 
appears to commence at the areola, extends over various parts 
of the body, it consists in the generality of cases, of small, cir- 
cumscribed, and slightly elevated spots. 

4th. The fourth period commences about the tenth day; the 
areola diminishes, the fluid contained in the vesicle becomes 
purulent, and at the same time it begins to dry at the centre, 
which assumes a brownish hue; on the following days the de- 
siccation continues, the areola and tumefaction gradually dis- 
appear, and the vesicle is soon transformed into a circular, hard 
scab of a deep brown colour, which shrinks and becomes 
blackish as it dries, and finally falls off about the twentieth or 
twenty-fifth day from the vaccination. Its disengagement 
discovers a scar which is depressed, circular, and honey- 
combed, exhibiting on its surface small pits, which indicate 
the number of cells of the vesicle; the traces left by this scar 
are indelible. 

Such is the regular course of vaccine, and the characters it 
ought to present, in order to fulfil all the indications that have 
been regarded as necessary to prevent the occurrence of small- 
pox. Accidental vaccine eruptions may be produced by the 
patients themselves, from their scratching the original pock, 
and then accidentally vaccinating themselves by means of 
their nails, which have become charged with the virus. 

As to the eruptions which occur during the course of the 
vaccine, in persons who have been exposed to the contagion 
of small-pox, and which many physicians have regarded as 
vaccine eruptions, resulting from the general action of the 
vaccine virus on the system, it is now known that they are 
mild cases of small-pox, modified by the vaccination. But, 
this fact is very remarkable and merits attention, for physi- 
cians have vaccinated with the matter taken from the suppos- 
ed vaccine vesicles, and have developed, they say, true vesi- 



VACCINIA. 163 

cles of cow-pox; but one of two things must happen; either 
they have been grossly mistaken, or else this disease, induc- 
ed by the vaccination, really had the appearance of cow-pox. 
In admitting the latter, what becomes of the distinction be- 
tween vaccine and certain varieties of small-pox? 

When the vaccination does not follow the course we have 
described, it may be regarded as incapable of protecting the 
system from variolous infection, and the name of spurious 
vaccine has been given it. 

Often instead of a vesicle, a true pustule is formed. The 
inflammatory action begins on the day of the vaccination, or 
at most on that succeeding it, the puncture becomes surrounded 
by a well-defined areola; the pustule rapidly augments in size, 
its centre is more elevated than the edges; on the fourth to 
the fifth day it is replaced by a scab of a yellowish-brown co- 
lour, which soon falls off and leaves no scar. 

The eruption may also be vesicular, but from its irregular 
progress, the disease that ensues will not serve as a protection 
against small-pox. 

Willan admits three false vesicular vaccine pock. 

1st. In one, the vesicle is perfect, but without an areola, or 
surrounding inflammation, on the ninth and tenth day. 

2d. In the other, the vesicle is pearl-coloured, and much 
smaller than the genuine vesicle: it is flattened, the margin is 
not rounded or prominent, the base is hard, inflamed, slightly 
elevated, and surrounded by an areola of a dark red colour. 

3d. In the third, the vesicle is smaller than in true vaccine; 
it is pointed; the areola is sometimes of a dilute red colour, 
and very extensive. 

In these two varieties the areola appears on the seventh or 
eighth day, and vanishes about the tenth. A scab is then form- 
ed which is smaller and more irregular than that which suc- 
ceeds the true vesicle, as is also the cicatrix. Even when the 
vaccine pock follows a regular course, some vaccinators think 
that the formation of purulent matter on the ninth day, indi- 
cates a vaccination which ought not to be depended on, and 
still less if the scab that succeeds it is small and friable. Con- 



X64 PUSTULAR DISEASES. 

slant chafing by the clothes, which breaks the vesicle and re- 
tards its progress, its being punctured too often to obtain the 
virus, may be considered as diminishing, in a greater or less 
degree, its anti-variolous power. Finally, we may regard as the 
cause of the appearance of the spurious vaccine, 1st The vac- 
cination of persons who have been already subjected to this 
operation, or who have had the small-pox. 2d. Vaccination 
with virus taken from a spurious vesicle, or even from a true 
one, but at too late a stage. 3d. The complication with scarla- 
tina, measles, gastro-enteritis, or even with some chronic cuta- 
neous affections, zsporrigo, eczema, prurigo, lepra, &c. 

Diagnosis.— The characters that have been already given 
will suffice to distinguish the true from the false vaccine. As 
to other eruptions, there is but the small-pox with which it may 
be confounded; but in the case of vaccine, the eruption is al- 
ways local, and the infection only takes place by inoculation, 
and there are seldom any general symptoms. The pustules 
are larger, of a silver-white, and the scars are of greater ex- 
tent, shallower, and present a peculiar character. 

Prognosis.— Cow-pox is a very mild disease, and in most 
instances is only accompanied by local symptoms. In some in- 
dividuals, however, it induces a little fever, or it is accompa- 
nied by a slight exanthema. In this case it only requires at- 
tention to diet and diluent drinks, but in most cases no treat- 
ment is necessary; care must be taken to prevent any chafing 
or pressure on the vaccine pock. 

In those instances where the eruption has appeared on the 
hands of persons who have attended horses having the grease, 
lemonades, emollient local baths, sometimes cataplasms to dimi- 
nish the swelling, one or two tepid baths and mild laxatives, 
are the only means that are necessary to be employed. 

When vaccine appears in an irregular manner from cogni- 
sable causes, the operation should be performed a second time. 
Even when the vaccination has been perfectly regular, a mul- 
titude of facts prove that the variolous contagion may still ex- 
ercise its influence on the system, but the disease that results is 
almost always very light, and does not pursue its regular march. 



VACCINIA. 165 

Several modes have been proposed to ascertain if the vacci- 
nation has exercised a sufficient influence on the constitution, 
to protect it from the variolous infection. The first consists in 
revaccinating, five or six days after the first operation ; a vesi- 
cle is the consequence, but it is surrounded by an areola al- 
most as soon as the first. The second plan is also to revacci- 
nate, but at the end of twelve days; if the first has produced the 
desired effect, an irregular vesicle only will occur on the se- 
cond. Finally, the best means certainly is, to test it by inocu- 
lating with variolous matter. A small pustule generally re- 
sults, which rapidly dries, and is unaccompanied with general 
symptoms. Sometimes, however, it produces a slight erup- 
tion, but this is usually very mild. But this means is not free 
from inconveniences. 

Notwithstanding the assertion of some physicians, the space 
of time that has elapsed since the vaccination, does not appear 
to modify in the least, the anti- variolous power of the cow-pox; 
for on the one hand, persons who have been vaccinated for 
twenty years, resist the contagion as well as those who have 
undergone the operation a few years or months before; and on 
the other, the small-pox, when it appears in vaccinated per- 
sons, is always modified, whether the vaccination had been 
performed but a few days, or whether years had elapsed. 

We have given the different appearances assigned by wri- 
ters to the spurious vaccine, but it should be remarked that 
the real nature of this spurious vaccine is far from being esta- 
blished, why it sometimes arises where true virus has been 
used, and finally, what are the causes that produce it. It is 
the more important that these questions should be answered, 
as it is clearly proved that persons who present cicatrices 
which are far from being those of true vaccine, resist the con- 
tagion of variola, and when it does attack them, induces an 
eruption as modified as if the vaccination had been perfect. 

What doubts ! what obscurity ! what anomalies ! Thus dif- 
ferent experiments have been made by inoculating with mix- 
tures of vaccine and variolous virus, and the result was sometimes 
vaccine, sometimes small-pox. If the two poisons be intro- 

22 



lf>(> PUSTULAR DISEASES. 

duced separately, but at the same time, and if the punctures 
are near each other, the local eruptions may become mingled, 
and the virus drawn from one side will produce cow-pox, and 
from the other, variola. In vaccinating a child exposed to the 
variolous contagion, it is sometimes entirely protected from its 
influence, sometimes, on the contrary, a modified small-pox is 
developed. Finally, in some cases, the variola appears in a 
confluent form, and pursues a regular march during the vac- 
cine eruption. 

Nevertheless, in vaccinating we intend to preserve the sys- 
tem from the variolous contagion, or at least to modify the 
eruption, and to dissipate all danger, and if incontestible facts 
exist, which prove that the small-pox is developed in vaccinated 
persons; it has also been known to attack the same individual 
after inoculation ; but notwithstanding these, which moreover 
are very rare, and seldom of a severe character, vaccination, 
without inducing any danger of itself, is still a preservative 
means of the highest grade of utility, and is perhaps the most 
glorious victory of the art of medicine. 

ECTHYMA. 

By the term ecthyma, Exdvput, pustular eruption, is meant 
an inflammation of the skin, characterized by phlysacious 
pustules, which are large, rounded, usually distinct, having an 
inflamed base, and which are succeeded by a thick scab, leav- 
ing on its disengagement sometimes a slight scar, but most 
generally a red spot, which lasts a considerable time. These 
pustules appear on all parts of the body, but they are more par- 
ticularly observable on the limbs, the shoulders, thighs, neck, 
and breast, but rarely on the face or scalp. Although, in 
most cases, widely separated from each other, they may attack 
large surfaces, or even the whole body; but they are generally 
confined to a single place. 

Causes. — Sometimes ecthyma is idiopathic, and produced 
by direct and appreciable causes; at other times it arises spon- 
taneously. 



ECTHYMA. 167 

In the first case it often results from frictions or irritating 
applications to the skin. Thus, real pustules of ecthyma arise 
in some instances from the use of the ointment of Authenrieth, 
or from the application of tartar emetic plasters. These pus- 
tules are contiguous to each other, and the epidermis is 
always distended to some extent by a purulent lymph; the ele- 
vation is usually umbilicated; they last some days, and are 
then replaced by scabs, which begin to form at the centre; the 
inflammation that accompanies them is sometimes active, but 
this is no disadvantage, as it is purposely induced as a means of 
cure for other diseases; where it becomes too violent, and is 
accompanied with pain, emollient applications should be re- 
sorted to. Idiopathic ecthyma is often produced by handling 
pulverulent or metallic substances, &c. It frequently occurs 
on the hands of grocers and masons, being induced by the ac- 
tion of sugar or lime. 

Ecthyma also appears spontaneously, and as symptomatic of 
some peculiar state of the system ; it attacks all ages, occurs at 
all seasons, but more especially during the spring and summer, 
in young persons and adults; women during pregnancy some- 
times suffer from it. It appears in most cases to be produced 
by great fatigue, excessive labour, long and continued want of 
sleep, deficiency of nourishment, uncleanliness, violent men- 
tal affections, &c. and the action of these causes is more 
prompt, if the patients should be guilty of excesses. 

Ecthyma also is developed during the active stage of certain 
chronic diseases of the skin, as lichen, prurigo, and above all, 
scabies; and also in the convalescence from some acute inflam- 
mations, as scarlatina, rubeola, and particularly variola. 
Finally, chronic irritations of the internal organs sometimes 
exercise an evident influence on the appearance of ecthyma, 
and in some rare cases, an eruption of ecthymatous pustules 
have been critical in acute gastro-enteritis. 

Ecthyma may be partial, and pass through its different 
stages on one spot. In these cases, it lasts from one to two 
weeks. It may be general, and occur on all parts of the body, 
but usually by successive eruptions, and thus last for weeks or 
even months. 



168 PUSTULAR DISEASES. 

Symptoms. — When the disease is partial, the eruptions 
may all appear at the same moment, but they commonly oc- 
cur in succession. It usually commences by red, inflamed 
points, which acquire a considerable size in a few days; their 
apex soon becomes prominent from the secretion of pus, whilst 
the base is hard, and of a vivid red colour; the purulent fluid 
dries in three or four days, and forms thick scabs, which leave 
spots of a deep red colour on their disengagement. The pus- 
tules are usually distinct, but sometimes they form irregular 
groups; the size varies from that of a small bean, to that of a 
franc piece, or even more. Their development is sometimes 
accompanied by violent pain. Suppuration, under some circum- 
stances, takes place very promptly, at other times, it does not 
occur for several days; occasionally, the pus is in small quan- 
tities, and only occupies the apex of the pustule, the base of 
which is large, hard, and of a vivid red; but it may also be so 
freely secreted as to elevate the cuticle over the whole of the 
inflamed surface, assuming the appearance of a bulla; and in 
such cases, the purulent fluid is often confined to the interior 
by a small, circular layer of a transparent serous liquid. This 
appearance usually occurs in the pustules that appear on the 
hands and feet. 

Some of the pustules disappear by resolution, and are suc- 
ceeded by thin, white scales; but in most cases, the suppura- 
tion occasions a thick, adherent crust, which leaves a deep red 
spot on its falling off, sometimes followed by a scar. When 
there has been a succession of pustules for some time, these 
red spots are numerous, and almost continuous; giving a pecu- 
liar appearance to the surface of the body, which is only ob- 
servable after ecthyma. The pustules may also occasion ul- 
cerations, particularly those which occupy the lower extremi- 
ties, and are the sequelae of scarlatina and small-pox. There 
is in such cases, much inflammation of their base, the scabs 
are thick, and the ulcer is generally ill-conditioned, sanious, 
bloody, and painful. 

In weakly, badly nourished, and cachectic children, and in 
those affected with enteritis, and its usual accompaniament, tu- 
mefaction of the abdomen, this eruption often occurs, (E. in- 






ECTHYMA. 169 

fantile, Will. ) In these instances, the pustules are commonly 
very irregular in size, their form is circular, and their colour 
of different shades of red according to the state of weakness of 
the child. Sometimes the large pustules break, and occasion 
a deep ulceration, which is at length replaced by a slight cica- 
trix. At other times, after having threatened to suppurate, 
they gradually diminish in size, and their surface undergoes se- 
veral successive desquamations. 

In persons advanced in age, who are cacochymic, and ad- 
dieted to drink, a variety of ecthyma closely resembling rupia 
is often seen, (E. cachecticum, Will. ) Its most usual seat 
is the legs, but all parts of the body may be affected. The skin 
is inflamed, and slowly swells, and to a greater extent than in 
other cases of ecthyma; it assumes a deep red hue, and, at the 
end of from six to eight days, the epidermis covering its sur- 
face is distended by a blackish exudation, mixed with blood; 
this soon breaks, and forms a thick, blackish scab, which is 
most elevated at its centre; its edges are hard, callous, and 
more or less inflamed; the scabs are very adherent, and are not 
detached for some weeks, they may even remain for months. 
If they are accidentally disengaged, an ill-conditioned ulcera- 
tion ensues, which is healed with difficulty. 

Sometimes general symptoms, as depression, anorexia, a 
slow fever, constipation, &c. precede, or accompany the erup- 
tion, but these symptoms usually disappear with it. In many 
cases, the lymphatic ganglions are engorged, and occasion vio- 
lent pain, which must be combated by emollient applications 
or local bleedings. Suppuration and desiccation are the most 
common terminations of ecthyma; resolution and ulceration 
occur but rarely. * 

Diagnosis. — The pustules of ecthyma are generally to be re- 
cognised with ease by their size, the inflammation of their base, 

* Dr. Hewson details a very interesting case of ecthyma, accompanied 
with two views of the eruption, in Vol. I, p. 89, of the North Amer. Med, 
and Surg. Journ. This case presented some anomalies not mentioned in our 
text; the eruption on the patient's breast somewhat resembled Pityria- 
sis. — Trans. 



170 PUSTULAR DISEASES. 

and their mode of development These characters will pre- 
vent their being confounded with acne, impetigo, mentagra, 
or porrigo. Nevertheless, when the pustules of acne or men- 
tagra present, (as is often the case, ) a hard and red base, they 
might be mistaken for the phlyzacious pustules of ecthyma, if 
the state of induration, rather than the inflammation of the 
base of the former, and the peculiar characters visible in a ma- 
jority, were not sufficient to prevent error. 

The umbilicated pustules of variola, the multilocular vesi- 
cles of vaccine, and their contagious nature, prevent these dis- 
eases from being confounded with ecthyma. 

It is more difficult to distinguish the pustules of ecthyma 
from those of a syphilitic nature, which present nearly the 
same characters, particularly as pustular syphilide may mani- 
fest itself by true ecthymatous pustules. In these cases, the 
coppery areola and concomitant symptoms must form the base 
for a diagnosis. 

Scabies will never be mistaken for this eruption, if it is re- 
collected, that there is no pustular itch, and if among the vesi- 
cles some pustules are found, the characters assigned to those 
of impetigo and ecthyma, will designate to which of these 
they belong; but it must be remarked, that those of the latter 
eruption are most frequently observed, and are in the greatest 
number. Besides, the small vesicles with which they are in- 
termingled will obviate all doubt. 

Ecthyma is distinguished from furunculus, from the first 
being an inflammation of the skin, which commences outward- 
ly, whilst that of the latter, occupies the subcutaneous cellular 
tissue, where it occasions mortification to a small extent, and 
terminates by expelling this portion of dead flesh through an 
opening in the skin. 

Finally, rupia offers much resemblance to ecthyma, and 
these two diseases sometimes appear to be two degrees of one 
and the same inflammation: they are often seen together, and 
if there are positive characters by which simple ecthyma may 
be distinguished from rupia, there are none by which they can 
be identified in cases of E. luridum, where the epidermis is 



ECTHYMA. 171 

distended by a blackish blood, and a thick scab is formed, 
which covers a deeply ulcerated surface. 

But an elevation of the cuticle occasioned by purulent se- 
rum, and constituting a true bulla, prominent scabs resem- 
bling the shell of an oyster or limpet, and finally ulcera- 
tions, which oftentimes are deep, differ from the phlyzacious 
pustules with a hard and inflamed base, and the irregular scabs 
and superficial excoriations of ecthyma, in a sufficient degree 
to enable us in all cases to distinguish rupia from ecthyma 
simplex. 

Prognosis. — Ecthyma is not a serious disease, its progno- 
sis varies according to the extent of the disease, the age and 
state of the patient, and the nature of the concomitant diseases. 
Treatment. — When the disease is partial, slight, and fol- 
lows a regular course, it only requires diluent drinks, simple 
or emollient baths, and low diet. If it is more severe, and ac- 
companied with much inflammation, a small bleeding may be 
ordered, or some leeches applied to the anus. 

When the disease is prolonged, particularly in persons of a 
broken constitution, the hygienic treatment holds the first 
rank. The patient is to use moderate exercise, and to live on 
nourishing food. He is to take simple or slightly stimulating 
or alkaline baths. Mild laxatives are useful, if their use is not 
counter-indicated by the existence of evident symptoms of 
gastro-enteritis. The patient must carefully avoid all excess 
in eating, the use of spirituous liquors, fatigue, &c. 

Sometimes recourse must be had to tonics, as the decoction 
of cinchona, ferruginous preparations, &c. 

The ulcerations which follow the detachment of the scabs, 
are generally ill-conditioned, and heal but slowly. If there is 
much inflammation, emollient applications are to be used, but 
on the contrary, it is generally necessary to excite the sur- 
face, either by touching it with nitrate of silver, or repeatedly 
washing it with aromatic or slightly stimulating decoctions. 
The hydrochloric acid, weakened with water, is sometimes 
very useful in exciting the surface and altering the inflamma- 
tory action. As this becomes increased, the ulcerations heal 
with great rapidity. 



172 PUSTULAR DISEASES. 



Impetigo. Dartre Crustacee. 



La dartre crustacee, (herpes crust aceus,) of Alibert, cor- 
responds to one of the forms of impetigo. He has divided it 
into three species: 1. Dartre crust ace" e flavescente, which 
corresponds with impetigo figurata, Will. 2. Dartre crus- 
tacSe stalactiforme, which is a sub-variety based on the form 
of the scab. 3. Dartre crustac&e en forme de mousse, which 
appears to resemble many different diseases. 

By the term impetigo is meant a non-contagious disease, 
characterized by an eruption oipsydracious pustules, general- 
ly contiguous to each other, which form thick, rugose, yel- 
low scabs. The pustules are sometimes grouped, and occupy 
a greater or less, but at the same time circumscribed extent of 
surface, and which generally has a regular form, constituting 
impetigo figurata, Will. Sometimes the pustules are scat- 
tered and are in irregular groups. This variety is termed by 
the same author impetigo sparsa. Many intermediate de- 
grees exist between these varieties, but they do not offer cha- 
racters of sufficient distinctness to be separately considered. 
Both may occur in an acute or in a chronic state. 

A. The Impetigo Jigurata, (Dartre crustacee flavescente, 
Al. ) generally appears on the face, and particularly on the 
cheeks; it is also observed on the limbs or even on the body. 
Children about the age of dentition, young persons and females 
of a sanguine or lymphatic temperament, whose colour is fresh 
and skin fine and delicate, are often attacked with it. It usu- 
ally occurs in the spring, and some individuals are periodically 
subjected to its invasion at this time, for many years in suc- 
cession. Its appearance is rarely accompanied with other ge- 
neral symptoms, than a slight uneasiness or head-ache. 

When this variety is developed on the face, it may occupy 
a very variable extent of surface. Sometimes one or more 
small, distinct, red spots are seen, which are a little elevated, 
and are soon covered with small, closely set pustules; these 
inflamed places may be isolated, or they may become united 



IMPETIGO. 173 

by the occurrence of pustules at their edges. Sometimes the 
eruption is more extensive, and the inflammation more active. 
Thus the two cheeks, or all the chin, may be attacked at the 
same time; and in this case, as in the former, there is much 
itching, and even a kind of erysipelas precedes and accompa- 
nies the eruption. This is pustular from the commencement; 
the pustules are small, conglomerated, and but slightly elevat- 
ed above the level of the skin. They do not remain long in 
this state, but in the space of thirty-six to forty-eight hours, or 
at most in three days, they break and effuse a purulent fluid. 

The heat, pruritus, and swelling, become at this time much 
stronger. The fluid, which is poured out in great abundance, 
rapidly dries, and forms scabs of different thicknesses, of a 
yellow colour, very friable, and semi-transparent, which some- 
what resemble the gum of certain trees, or dried honey. The 
weeping continues, the scabs increase in thickness, and it is 
in this state that patients usually come under the notice of a 
physician. Scabs of a yellowish-green colour, friable, and of 
various degrees of thickness, are now seen; these cover a red, 
inflamed surface, of an irregular circular form, from which a 
sero-purulent fluid is discharged. 

Towards the edges of this surface, there are still found un- 
broken, psydracious pustules, and also some on which the ef- 
fused fluid has scarcely coagulated. The features are scarcely 
recognisable if the disease is of any extent. 

Impetigo Jigurata remains in this state from two to four 
weeks, if it is not prolonged by successive eruptions: when the 
heat and itching diminish, as does also the weeping, and the 
scabs fall off in an irregular manner; the exposed surface is red 
and tense; and there are often small fissures from which a fluid 
is discharged and forms fresh scabs, but much thinner than the 
former. When the crusts are finally detached, the skin re- 
mains a long time redder than natural, it is shining, the cuti- 
cle is very thin, and a slight chafing will sometimes reproduce 
the disease. 

Impetigo Jigurata may only occupy a small space at its 
commencement, and afterwards extend by the successive de- 

23 



174 PUSTULAR DISEASES. 

velopment of psydracious pustules at its edges; in these cases 
desiccation begins at the centre of the eruption. 

Sometimes reiterated eruptions prolong the disease for 
months and years, and although it is then chronic from its 
duration, the successive inflammations are all acute. The 
causes which thus lengthen the disease are excess in food, the 
use of stimulating applications, as caustics, or the injudicious 
employment of the sulphurous remedies. In these cases the 
skin may become inflamed to some depth, and thicken, but 
the diseased surface never presents that state of dryness, that 
is observed in some attacks of chronic Impetigo Jigurata, 
where it is situated on the limbs. 

Impetigo Jigurata of the face only occurs on a very small 
space. We have seen it in the Hospital of St. Louis, confined 
to the eyelids, and there form elevated, conical scabs, that 
Alibert has compared to the stalactites in certain caves. It 
kept up a chronic ophthalmia. At other times we have ob- 
served it around the upper lip, and extending downwards on 
each side equally, so as to present a uniform appearance, 
of about five or six lines in length, somewhat resembling a 
pair of mustachios. 

Impetigo Jigurata may occur on the limbs and body. 
When it occupies the lower extremities, the diseased spots 
are usually of a large size, and of an irregular oval form, 
whilst they are smaller and more circular on the arms. The 
pustules are developed in the same manner as on the face; 
they are soon followed by thick scabs of a greenish or brown- 
ish yellow. When they fall off, others are formed by the dry- 
ing of the sero-purulent fluid that is secreted from the inflam- 
ed surface. The duration of the disease is very variable; some- 
times it becomes chronic, but then successive eruptions of 
pustules do not take place; they only appear from time to time 
on some point of the inflamed surface, particularly about the 
edges. The dermoid tissue itself appears to be inflamed to a 
certain depth, and acquires a morbid thickening. On the same 
individual may be found scabby patches of this eruption of a 
large size; sometimes one large patch occupies the internal 



IMPETIGO. 175 

part of one of the thighs, whilst others are found on the ex- 
ternal portion, or on the leg, and in some cases on the abdo- 
men. In some instances the scabs that cover these patches ac- 
quire a great thickness, and the disease corresponds to the 
Impetigo scabida, Will. 

When the disease is chronic, no pustules may be visible, but 
the peculiar form of the patches, that of the scabs, and the par- 
tial eruptions that occur from time to time, will always suf- 
fice to characterize it. 

When a cure takes place, either naturally, or from medical 
treatment, the heat and itching diminish, the effusion of lymph 
becomes less abundant, and the scabs thinner; the edges begin 
to dry, and in a short time the diseased surface does not form 
scabs; though the skin regains its natural colour but slowly in 
these spots. 

B. Impetigo sparsa only differs from the preceding by the 
irregular and scattered distribution of its pustules, except 
which, it follows the same course, and equally gives rise to 
thick, rugose, yellowish-green scabs. This variety is particu- 
larly prevalent in the autumn; it continues during all the win- 
ter, and disappears about the commencement of the spring. It 
has more tendency than the other variety to pass into the 
chronic state. La t eigne muqueuse, Al. appears to be identi- 
cal with this variety of impetigo. 

Although it may occur on all parts of the body, Impetigo 
sparsa particularly affects the limbs, above all at the arti- 
culations. Its peculiar seat seems to be the legs. Some- 
times it is confined to one spot, and at others, covers a whole 
limb, or even several at the same time. 

The pustules are developed in the same manner as in the 
preceding variety, but, instead of being grouped, they are ir- 
regularly scattered on the diseased surface ; they are accompa- 
nied by violent itching and soon break. Yellow scabs rapidly 
form from the partial drying of the effused sero-purulent fluid; 
these scabs are rough, thick, friable, and do not form large la- 
minae, like the scales of eczema; they soon cover the whole 
diseased spot, but in most cases detached pustules are to be 



176 PUSTULAR DISEASES. 

seen. At this period the disease corresponds to the dartre 
crustace'e of Alibert. When the scabs fall off, either naturally 
or under the influence of medical treatment, an inflamed sur- 
face appears, offering here and there, superficial excoriations, 
and a few irregularly dispersed pustules; a sero-purulent fluid 
exhales from this surface, and in partially drying, renews the 
scabs. This weeping is often very abundant, and soon em- 
bues any dressings that may be applied. 

In some cases, and especially in individuals of a certain age, 
whose constitution is injured, the scabs acquire great thick- 
ness; they are of a deep yellowish-brown, and have been com- 
pared to the bark of a tree by Willan, who has termed them 
Impetigo scabida. Sometimes these scabs encase a whole 
limb, and renders its motions difficult and painful ; there is at 
the same time much heat and a very uncomfortable itching. 
These thick crusts split in a short time, and when portions be- 
come detached a new scab is formed in its place. When the 
disease is thus violent, and occupies the lower limbs, it is some- 
times complicated with anasarca and extensive ulcerations. If it 
reaches the toes, the nails may be destroyed, which when they 
reappear, are thick and irregular, as in certain cases of lepra 
and psoriasis. 

Finally, impetigo, although usually unaccompanied by ge- 
neral symptoms, may, nevertheless, under certain circum- 
stances, be attended with a strongly marked inflammatory dia- 
thesis. We have seen several patients at the Hospital of St. 
Louis, in whom there existed at the same moment, a general 
derangement of the functions, fever, a burning pain, much 
heat, and an erysipelatous injection of the skin, (I. erysipe- 
latodes, Will.) 

It may be well supposed, that there exists a multitude of in- 
termediate stages, which it is impossible to describe, but which 
are more or less allied to one or the other. 

The duration of impetigo is very variable, it may terminate 
in three or four weeks, or it may be indefinitely prolonged. 

Causes. — Certain external causes may develope this disease, 
by acting in a direct manner on the skin; such are the erup- 



IMPETIGO, 177 

lions that so often appear on the hands of individuals who 
work among irritating substances, as raw sugars, lime, or me- 
tallic powders. The same causes often induce pustules of ec- 
thyma. Impetigo is observed at all seasons, but especially in 
the spring and autumn. Children at the time of their denti- 
tion, and women at the critical period, are particularly liable 
to it. It has been remarked that persons of a lymphatic or 
sanguine temperament, whose skin is fine, and whose colour 
is fresh, are peculiarly predisposed to it. Any excess or vio- 
lent exercise, sometimes appear to occasion this disease, and 
strong mental affections, especially grief and fear, exert in 
some cases, a remarkable influence on its development. Im- 
petigo is often complicated with other diseases of the skin, 
and above all with lichen. 

Diagnosis. — The occurrence of psydracious pustules, either 
in groups or scattered, giving rise to thick, rough, yellow 
scabs, will suffice to distinguish impetigo from the vesicular or 
vesiculo-pustular eruptions of eczema, which are succeeded by 
thin lamellar, or scaly scabs, and in which are constantly to 
be recognised the elementary lesions or vesicles. 

When impetigo figurata is situated on the chin, .attention 
is requisite not to confound it with mentagra. In impetigo, 
the pustules are small, yellow, aud contiguous, the weeping 
of serum is abundant, the scabs are thick, of a greenish-yellow, 
and semi-transparent, and besides which there are neither cal- 
losities nor tubercles: the pustules of mentagra are larger, less 
yellow, isolated, and more prominent than those of impetigo, 
the weeping is much less abundant, and the scabs are drier, of 
a deeper colour, and are not reproduced. 

Impetigo of the scalp may be mistaken for different species 
of porrigo. The distinct pustules of porrigo favosa, which, 
firmly adhering to the cuticle, are transformed into dry, yel- 
low scabs, in the form of cups. The pustules of the same kind 
of porrigo scutulata, which, by their aggregation, are still 
more allied to impetigo, will suffice to distinguish them ; besides, 
these two species of porrigo are contagious, and occasion a loss 
of the hair, two circumstances that do not occur in impetigo. 



178 PUSTULAR DISEASES. 

The nature of the scabs in la teigne granulee, (porrigo 
scutulata, var. Will.) which have been compared to frag- 
ments of plaster, distinguishes impetigo from this affection: 
as to porrigo larvalis, it offers the same characters as impetigo 
sparsa or erysipelatodes. 

When impetigo is complicated with scabies, the slightest 
attention will suffice to recognise the vesicles; it must be re- 
membered that the pustules, which in almost all cases are com- 
plications, are always either psydracious pustules of impetigo, 
or phlysacious pustules of ecthyma. 

The thick crusts formed on the face in syphilitic ulcerations, 
have been taken for those of impetigo, even by persons who 
might be supposed to be conversant with the differential diag- 
nosis of diseases of the skin. There exists at this moment in 
the Hospital of St. Louis, a patient who has every character 
of the best marked syphilide, and who was a few months since 
treated in vain at the Charite for an impetigo Jigurata. Large, 
black, thick, adherent scabs, covering violet-looking ulcers, 
and here and there environed by indelible scars, and leaving, 
on their falling off, deep ulcerations, a certain rounded form 
of the eruption, taken generally, and a peculiar aspect which 
it suffices to have seen but once to never mistake it, are cha- 
racters sufficiently marked to have prevented so gross an 
error. 

Prognosis. — Impetigo is not a disease that endangers the 
life of a patient, and consequently the prognosis is not fatal; 
but if it is without danger, it is very uncomfortable, and often 
extremely repulsive. In making a prognosis, great care must 
be taken not to promise a speedy cure; a promise that time 
often belies. The disease is more severe when it is of long 
continuance, and when the patient is old or of an injured con- 
stitution, than if it be acute and the patient young and robust. 

Treatment. — In the treatment of impetigo, the utility of 
sulphurous preparations has been admitted on too wide a basis, 
and they are too often resorted to in the commencement as a 
specific. Instead of being constantly useful, their injudicious 
employment often aggravates the disease and greatly prolongs 



IMPETIGO. 179 

the attack. In general, they should not be used in the com- 
mencement. When the impetigo is of little extent, and the 
symptoms of local irritation slight, emollient lotions of decoc- 
tion of mallows, of poppy heads, tepid milk, scalded bran, or 
emulsion of almonds, are all that are necessary. The patient 
should take some cooling drinks. But if the disease is exten- 
sive, if it occupies a greater or less part of the face, recourse 
must be had to blood-letting, either local or general, paying 
attention to the strength of the patient. Both are sometimes 
indicated. Venesection in the foot, and one or more applica- 
tions of leeches to the mastoid apophyses or the anus, will ful- 
fil this double intention. 

When the disease occupies so irritable a spot as the face, it 
is highly necessary to bleed at its very commencement; this 
means is also useful in cases of impetigo figurata, fixed on 
this part, and which has been aggravated by a stimulating treat- 
ment. Emollient lotions, and at the same time laxatives, as 
infusion of chicory with half an ounce of sulphate of magne- 
sia or soda, to the pint, should be conjointly employed. 

General baths are also very useful, even when the disease is 
fixed in the face, for they act by diminishing the general 
erythism; but they should be 25° to 27°, Reaumur, (88° to 
92°, Far.) used hotter they might occasion a dangerous conges- 
tion in the head. When the inflammation is diminished, weak 
alumnised lotions may be substituted for the emollient. These 
simple means are sufficient in many cases, and towards the end 
of the treatment, baths, and douches of vapour, may be advan- 
tageously employed, these are particularly useful if the dis- 
ease is obstinate, as they appear to act by changing the action 
of the skin. 

In these cases, more energetic measures must be had re- 
course to, and purgatives have been followed with the greatest ! 
success in most instances. But at the same time, due regard 
must be paid to the state of the digestive organs. Those which 
are most employed are calomel, Epsom and Glauber salts, ja- 
lap, and castor oil. Under the same circumstances, acidulated 
drinks may be given to the patient, made by adding from 



180 "PUSTULAR DISEASES. 

half a drachm to a drachm of sulphuric acid to a pint of water. 
He should also take tepid baths, either local or general, and 
rendered alkaline by the addition of subcarbonate of soda or 
potash. Lotions of the same nature should be also used on the 
eruption. These may be alternated with acidulated washes, 
particularly of the medicinal hydrocyanic acid in the propor- 
tion of two or three drachms to half a pint of distilled water, 
with the addition of half an ounce of rectified alcohol. It is 
necessary before using these different lotions, to cleanse the 
diseased surfaces as much as possible from the scabs that cover 
them. This may be done by a repeated and prolonged use of 
tepid baths. 

When the disease thus passes into a chronic state, the sul- 
phurous preparations are advantageous, and have produced 
happy results. The~ mineral waters of Bareges, Enghien, 
Bonn, and Cauteretz, are the most generally employed. They 
may be either taken as baths or internally; in the latter case, 
either alone or with milk. Sea-bathing is also very useful. 
The artificial sulphurous baths are prepared by the addition 
of from two to four ounces of sulphuret of potash to a bath. 
This preparation may also be used as a lotion. Vapour-baths, 
and especially douches, directed on the patches of Impetigo 
Jigurata, are very successful when this disease is in a chronic 
state. The patient should keep himself at some distance from 
the jet of vapour, and make use of this remedy for about ten 
to twenty minutes each time. 

These means combined and employed judiciously, will often 
cure the most obstinate cases of impetigo, and may be used, 
not only with the young and vigorous, but also with the aged 
and enfeebled. 

In some cases, all these remedies are unproductive of the 
desired result, and it has been proposed to cauterize the dis- 
eased surfaces with a diluted acid, and the preference has been 
given to the hydrochloric, which, it has been said, never oc- 
casions scars; but this is a mistake, and any other acid will 
fulfil the same intention, that of changing the action of the 
skin. In confining the use of caustics to those cases which 



ACNE. 181 

have resisted other modes of treatment, the accidents that re- 
sult from its injudicious employment will be avoided. In such 
cases, this plan has often been followed by beneficial results. 
They may be made with either a weak solution of nitrate of 
silver, or with an acid. To apply them, a camel's hair pencil 
should be dipped in the solution, and then applied over the 
whole of the diseased surface, which is to be immediately af- 
terwards well washed with water, to prevent the caustic from 
acting too violently. 

Under similar circumstances, the ointment of the proto- 
nitrate of mercury has been very successful; it is made by add- 
ing from one scruple to one drachm of the salt to an ounce of 
axunge, according to the excitement that is wished to be pro- 
duced. It is sometimes useful, where the eruption is exten- 
sive, to modify the morbid action, by the application of a blis- 
ter to the diseased surface. 

All these means are oftentimes of no avail ; the disease will 
then require still more energetic treatment, and the arsenical 
preparations are sometimes followed by unlooked for success. 
Pearson's solution will often produce a rapid and permanent 
eure. It is at first used in the dose of a scruple to half a 
drachm, which may afterwards be increased to a drachm daily. 
The use of this preparation should be relinquished for a few 
days, and again resumed, and is thus to be continued for a month 
or six weeks, taking care to keep the digestive organs in a 
good state. * 

Acne. Couperose* Gutta rosea. 

The word */lcne, from d^w or *xm> has been given to 
this disease, because it often, affects young persons of both 

* Dr. Hendrie has given some instances in the Philadelphia Journal of the 
Medical and Physical Sciences, Vol. VIII. p. 400, where obstinate cases of 
impetigo were cured by means of the expressed juice of the Sanguinaria 
canadensis. This being an acrid and stimulating application, may succeed 
in chronic cases. It being a common plant throughout our country, renders 
a further trial of its powers in eruptive diseases very desirable. — Trans, 

24 



182 



PUSTULAR DISEASES. 



sexes about the age of puberty. Aetius, and afterwards 
Sauvages, employed this term, which was also adopted by 
Willan. 

To the varieties which constitute the genus acne, may be 
referred la dartre pustuleuse couperose and la dartre pus- 
tuleuse mili'aire, Alibert. 

This disease is a chronic pustular affection, characterized by 
the presence of small isolated pustules, whose base is more or 
less hard, of a deep red colour, and which often forms after the 
disappearance of the pustule, a small, hard, red, circumscrib- 
ed tumour, nearly indolent, the resolution of which takes 
place but slowly. This disease is observed from puberty to 
the age of thirty-five or forty, but it is most violent in young 
persons. Both sexes are equally subject to it. 

The pustules of acne usually appear on the face, and parti- 
cularly on the forehead, temples, chin, and sometimes on the 
neck, shoulders, and upper part of the breast, but their most 
common seat is the posterior and superior part of the body; in 
some cases, the back is studded with them. 

Acne exists in this situation on a multitude of individuals, 
whose face is entirely free from them, whilst, on the contrary, 
when it occurs on the face, it generally also appears on the 
back. The limbs are never subject to it, except where it exists 
over the whole of the back, when a few pustules may be found 
on the posterior part of the arms. 

Three varieties of acne may be admitted, not only as facili- 
tating the study, but also from their presenting some differ- 
ences, though it is impossible to draw a marked line of demar- 
cation between them, for the same individual may be simul- 
taneously attacked with all three, or at least in rapid succes- 
sion; they have been denominated by Willan, tflcne simplex, 
indurata, and rosacea. As to Jicne punctata, which is also 
admitted by this author as a distinct variety, it is nothing but 
a complication that may occur in the two first, and consists in a 
morbid accumulation of sebaceous matter in the follicles which 
secrete this substance. The orifice of the follicles presents a 
black point, giving a peculiar aspect to the disease. 



ACNE. 183 

Acne has been regarded as a tubercular disease by Willan 
and Bateman, but Professor Alibert has assigned it its true 
place in arranging it with the pustules, and M. Biett, also 
adopting this opinion, has long since described it as a pustular 
eruption. In fact, the circumscribed indurations of the skin, 
which have received the name of tubercles, and are so often to 
be seen in this disease, are only a termination of pustules, and 
do not constitute an elementary lesion. 

Some authors, and particularly Plumbe, regard the pustules 
of acne as the result of inflammation of the sebaceous folli- 
cles, which is produced and kept up by the matter secreted 
in them. There is no doubt, but that we find on the face, and 
on the chin especially, small pustules which evidently result 
from this cause, and from which can be squeezed a small oval 
body, formed by hardened sebaceous matter, and moreover a 
morbid accumulation of this substance accompanies many cases 
of acne, (Ji. punctata,) but this is far from constituting a 
genus, it would be a variety at most, and perhaps only a com- 
plication. Indeed, we often see persons whose follicles are in 
this state, and yet who present no traces of acne. This latter 
disease, on the contrary, may exist without being accompani- 
ed with this state of the follicles, and when it is complicated 
with it, these black points never change into true pustules of 
acne; finally, by compressing these last, at the period of sup- 
puration, pus escapes, and not hardened sebaceous matter. 

Jicne simplex particularly affects young persons about the 
age of puberty; it occurs on the spot where the whiskers will 
appear, or on the forehead: it is often observed in girls about 
the time of their first menstruation. A multitude of young 
and robust individuals enjoy perfect health, whilst their shoul- 
ders and the upper part of their thorax may be covered with 
this eruption. These pustules usually appear in succession, 
in the form of small, inflamed points, which soon become pus- 
tular, having their base surrounded with a red areola; they 
pass through their respective stages, without occasioning any 
general symptoms; and commonly without pain or local heat. 

It is not rare to see individuals attacked with a considera- 



184 PUSTULAR DISEASES. 

ble eruption of pustules of Acne simplex, on the back, and be 
wholly unconscious of their existence. Sometimes, as occurs 
in girls, the pustules appear to be developed simultaneously, 
and in great numbers, in some cases covering the whole fore- 
head. In general, if they exist in considerable quantity, the 
sebaceous follicles seem to experience a certain degree of irri- 
tation, for the skin appears unctious and shining, the process 
of suppuration is slow, sometimes it does not commence for 
eight days, or even later, the pus is in small quantity, a very 
thin scab is formed, which soon falls off: it is sometimes scarce- 
ly perceptible; at other times the suppuration is more abundant, 
this especially takes place on the back, the scab is then thicker, 
but is soon detached by the chafing of the clothes. Even when 
the pustules are contiguous, they never become covered with 
thick crusts, as those of mentagra, under certain circumstances. 
When the suppuration is finished and the scabs fallen off, a 
red and slightly elevated point remains, which gradually dis- 
appears; at other times the redness and tumefaction continue; 
if this is the case in many of the pustules, and at the same time 
if others appear, the disease approaches more or less to the 
state of Jicne indurata, and may even present all the charac- 
ters of it. 

The pustules of A. simplex are often intermingled with 
small, black points, formed by the accumulation of sebaceous 
matter in the follicles. 

In Acne indurata, the inflammation of the skin is deeper, 
the suppuration is more slowly established, and after it is over, 
the skin and subcutaneous cellular tissue present partial indu- 
rations of greater or less extent. This variety usually affects 
the face, but it is also frequently observed on the posterior 
part of the thorax, and we have seen several cases in the Hos- 
pital of St. Louis, where it covered the whole posterior part 
of the body. It particularly attacks young persons, but it is 
always difficult to assign the cause; we frequently see it in 
individuals who are strong, robust, and enjoying perfect health ; 
at other times it occurs in young persons addicted to onanism, 
or even in individuals subject to abdominal irritations. Some 






ACNE. 185 

occupations appear to predispose to it, as those in which it is 
necessary to keep the head low and near a furnace. It may 
be very light; some points of inflammation may appear on the 
temples or masseter regions ; a pustule slowly rises, and suppu- 
ration is established in two or three weeks, or even, though 
rarely, does not occur at all. Other pustules form and sup- 
purate; the skin at the base remains hard and red, and the 
subcutaneous cellular tissue assists in forming a kind of tuber- 
cle or chronic induration. 

But in other cases the disease is much more violent, and the 
features of the face may be entirely disfigured. The face, in 
such instances, is studded with tubercles of a livid red, parti- 
cularly along the lower jaw, on the temples, lower part of the 
cheeks, and nose; a multitude of pustules, either just arising 
or in a state of suppuration, occupy the intervals between the 
tubercles, and are disseminated on other parts of the face; 
there are besides, red spots, and here and there thin scabs. 
The skin appears of a red colour, but this redness is greater 
in some spots. Often, instead of all these symptoms, a num- 
ber of black points, resulting from the accumulation of seba- 
ceous matter in the follicles, occupy the nose, cheeks, and 
masseter regions, in fact, all the intervals that exist between the 
pustules and tubercles. The skin is then shining and greasy, 
the subjacent cellular tissue is engorged, and the deformity 
is very great. Nevertheless, the general health may remain 
good, and the patient attend to his occupations. Sometimes, 
there may be cephalalgia, or an uncomfortable sensation of 
heat in the face. 

When Acne indurata occupies the back, it may be light, 
or may present all the above-mentioned symptoms, without 
the face being in the slightest degree affected. In these cases, 
as when it appears on the face, the duration of the disease 
is very long, and it is impossible to fix the time of its dis- 
appearance. When this takes place naturally, or from me- 
dical treatment, it is always very slowly, and the patients re- 
main predisposed to fresh attacks. 

The pustules of Acne indurata often leave indelible marks, 



186 PUSTULAR DISEASES. 

and it is not rare to find persons whose backs are covered with 
small scars, which are the remains of former eruptions of this, 
kind. 

The third variety, or Acne rosacea , differs from the preced- 
ing, from usually occurring in adults, and by being accompa- 
nied with an erythematous redness of the skin of the face. 
This variety often affects females at their critical period, those 
who indulge in drink or high living, and those who lead too 
sedentary a life. It frequently results from an hereditary pre- 
disposition; it is often observed in plethoric individuals who 
are subject to haemorrhoids. In young persons who appear to 
have great hereditary predisposition to this disease, there is 
often observable, after a prolonged exposure to the sun, or af- 
ter violent exercise, or great excess, red, irregularly circum- 
scribed spots, situated on the face, sometimes occupying the 
cheeks, sometimes the nose, or even the whole face, which 
then presents a peculiar appearance, but this red tint is only 
transitory; sometimes several scattered pustules may be deve- 
loped at the same time. 

In adults, this disease generally commences on the nose; 
the extremity of this organ assumes a violet red colour, after 
a slight excess, or even after an ordinary and simple repast. 
Gradually this redness of the nose becomes habitual, and gives 
a peculiar aspect to the physiognomy. Some pustules are de- 
veloped here and there, but suppuration does not take place, 
or if it does, it is in an incomplete manner; in these points 
the redness becomes more vivid. Sometimes the disease is 
confined to the nose, which acquires, after a certain tin 
a very large size. The cutaneous veins become varicose, and 
form bluish lines irregularly disposed, which contrast strong- 
ly with the red colour of the diseased part, but this augmen- 
tation of the nose does not always occur, its form is only al-l 
tered; the disease extends to the cheeks, forehead, chin, audi 
finally covers the whole face; the red tint is not uniform in 
every part, it is strongest where there are any pustules; sup- 
puration does not take place freely; there always remains a 
kind of induration, and the skin preserves an injected appear-l 



ACNE. 187 

ance. When the disease has lasted for some time, the skin 
of the face becomes rough and granulated ; and even if the dis- 
ease disappears, it never recovers its natural state. 

Acne rosacea is often connected with a chronic affection of 
the gastro-intestinal apparatus. The redness is generally in- 
creased in the evening, or after dinner. Finally, it may dis- 
appear and return on the same individual, each time differing 
in its violence. The pustules are numerous, and the yellow 
colour of their summits has an extraordinary appearance on 
the livid red of the face. In all cases, the features are more 
or less altered, and sometimes the appearance of the patient is 
highly repulsive. 

Causes. — We have indicated, when speaking of each va- 
riety, those causes which appeared to exercise the greatest in- 
fluence on their development; as excesses at the table, certain 
professions which require the head to be inclined, and parti- 
cularly where it is at the same time exposed to a violent heat; 
strong mental affections, cold drinks, some local applications, 
cosmetics, irritating lotions, &c. Acne rosacea, in particular, 
is often connected with a chronic affection of the mucous mem- 
branes, either of the stomach or intestines, and in some cases, 
with a morbid alteration of the liver. In general, all that 
tends to check or increase the circulation of the blood to and 
from the head, will cause this affection in persons who are pre- 
disposed to it. 

Diagnosis. — Acne is ordinarily to be easily recognised. Ec- 
thyma, and some cases of syphilitic tubercles, can alone be 
confounded with this eruption; but the pustules of acne are 
small, their progress is slow, and their base remains hard for a 
long time, whilst those of ecthyma are large and superficial, they 
are never accompanied with chronic indurations, and form 
thick scabs, which are more or less prominent, and which are 
never seen in acne. The peculiar appearance of syphilitic pus- 
tules, which are surrounded by a copper-coloured areola, with 
large, shining, flat tubercles, of the same hue, will easily dis- 
tinguish syphilide from acne; besides, there always exists in 
secondary syphilis, other symptoms indicative of the disease. 



188 



PUSTULAR DISEASES. 



Thus, the syphilitic tubercles are usually ulcerated at the sum- 
mit, particularly when on the alas of the nose, the angle of the 
lips; and the pharynx and palate, present unequivocal marks 
of the disease. 

Acne can never be confounded with dartre rongeante, (Lu- 
pus,) when this is in an advanced stage, though at its com- 
mencement, as it only presents a few scattered tubercles on 
the cheeks or nose, there may be some difficulty in distinguish- 
ing them from those of acne, but then, no pustules are formed 
as in the latter disease. They are not surrounded by the ery- 
thematous colour that almost always accompanies acne, when 
occurring in such a situation; they are larger, flattened, and of 
a rosaceous colour; they give rise to a certain degree of de- 
squamation, and are accompanied by a species of subcutaneous 
turgescency. 

Prognosis. — The prognosis varies with the variety. Thus, 
Acne simplex is often of very short duration, and is unattend- 
ed with any inconvenience. Acne indurata is much more 
troublesome, particularly when it is extensive and violent; it 
is very often exceedingly obstinate under the best regulated 
treatment. Finally, Acne rosacea is an affection that is very 
seldom curable. Besides this, the prognosis must vary ac- 
cording to the length of time the disease has lasted, the con- 
stitution of the patient, &c. 

Treatment. — The treatment of acne offers marked differ- 
ences, not only according to the variety that is to be combated, 
but also, according to its causes, the state of the patient's 
health, and the relative duration of the disease. 

When the pustules of Acne simplex are few in number, they 
scarcely merit attention; but when the eruption is abundant, 
recourse must be had to various local and general remedies. 
Thus, a cooling regimen; and for drink, whey, or an infusion 
of chicory, should be prescribed to the patient; at the samel 
time he is to be recommended to abstain from the use of wine, 
spirituous liquors, and coffee. If the patient is young and vi- 
gorous, venesection may be practised, particularly if the dis- 
ease attacks young persons about their first menstrual period.) 



ACNE. 189 

and this discharge should be excited by semicupiums, the ap- 
plication of leeches to the upper and inner part of each thigh, 
or by directing douches of vapour to the genital parts; lotions 
of scalded bran, emulsion of bitter almonds, of warm milk, or 
a decoction of quince seeds, will greatly assist the treatment, 
when chronic indurations remain; means must be used to has- 
ten their resolution; these will be indicated when speaking of 
the next variety. 

In Jlcne indurata, bleeding, either local or general, is al- 
most always indicated even in individuals who do not at first 
appear to possess a strong constitution; they should be repeat- 
ed as often as there is occasion, and antiphlogistic regimen 
and cooling drinks insisted on. But other means must be re- 
sorted to, to hasten the resolution of the tubercles, and to en- 
deavour to excite some action in the diseased parts. For this 
purpose, lotions of rose water, of sage, or lavender, are useful, 
to which is to be added a certain quantity of alcohol, accord- 
ing to the state of the pustules; it should be a quarter, a third, 
or even a half, if it is wished to create much excitement of the 
inflammation. A lotion, that is often beneficial in these cases, 
is a solution of five or six grains of corrosive sublimate in half 
a pint of distilled water, to which is to be added one ounce of 
rectified alcohol. Gowland's lotion, so much employed in 
London, for this affection, does not appear to be any thing but 
a solution of this mercurial preparation, with the addition of 
some emulsion. Another very advantageous means consists 
in frictions on the pustules and tubercles, with a mixture of 
the ammoniacal protochloride of mercury , in the proportion 
of a scruple or a drachm, to one ounce of axunge. The addi- 
tion o^ the ammonia to the calomel, appears indispensable to 
obtain the desired result. 

But of all the preparations to hasten the resolution of the 
tubercles in acne, none appears to us equal to the Ioduret of 
sulphur mixed with axunge, in the proportion of twelve, fif- 
teen, or even twenty-four grains to the ounce. For eighteen 
months past, M. Biett has employed it in his wards with asto- 
nishing success in a multitude of different eruptions, and among 

25 



190 PUSTULAR DISEASES. 

others, we have seen the worst cases of Acne indurata yield 
to it, and the tubercles disappear with surprising rapidity. 

Baths, and above all, douches of vapour, directed for twelve 
or fifteen minutes on the face, may efficaciously co-operate 
with the other means, which, if properly employed, will ren- 
der cauterizations wholly unnecessary, either with nitrate of 
silver or hydrochloric acid. Besides, it is very difficult to re- 
strain the action of these caustics within proper limits, for if 
they should penetrate too deep, they will give rise to large 
and painful ulcerations, and sometimes leave deep scars. 

In some instances it is advantageous to change the morbid 
action of the skin, by the successive application of blisters, par- 
ticularly if the eruption is confined to a small space. We 
have seen in the Hospital of St. Louis, this means crowned 
with the happiest success. If during the treatment new erup- 
tions should appear, or if the congestion towards the head 
seems unabated, no hesitation should be entertained of resort- 
ing to one or more detractions of blood; and at the same time, 
according to the state of the eruption, the use of repellents is 
to be suspended or continued; they are to be relinquished if 
there is much inflammation, the tubercles painful, and the 
pustules numerous; they are to be persisted in, on the con- 
trary, if the tubercles are hard, indolent and large. 

1st. Purgatives should be banished from the treatment of 
this disease; laxatives may, in certain cases, aid the action of 
other means, particularly in strong and robust individuals 
whose intestinal canal is in a normal state, and where there is 
a marked congestion towards the head. 

2d. The sulphurous mineral waters, especially those of Ba- 
reges, Enghien, Cauteretz, Aix in Savoy, &c. may J^ em- 
ployed with advantage, either externally, as lotions, or inter- 
nally. As general baths, they have less effect, and simple baths 
not hotter than 26° to 27°, (90° to 92°Fahr.) produce a better 
result. Patients should take two or three a week. 

When acne disappears, cold sulphurous douches have often 
been used by M. Biett with great success, particularly where 
the disease was complicated with the black spots, &c. 






MENTAGRA. 191 

The treatment of Jicne rosacea differs in many respects 
from that of the other varieties. Here blood-letting should 
in most cases be local. It is often advantageous to apply se- 
veral leeches near the affected parts, but when the eruption 
affects females at the critical period, the application is attend- 
ed with the happiest consequences. It must be remembered 
that this variety of acne is very obstinate; topical remedies, 
the employment of which is so often useful in Jicne indurata, 
are much less advantageous in these cases, and may even be 
injurious. In Acne rosacea, all the treatment should consist 
in hygienic measures. The abstraction of all causes that may 
exert any influence on the development of the disease, such as 
excess in eating or drinking, the use of spirituous liquors, &c. 
a regular and sober mode of living, a regulated diet, habitually 
composed of white meats, fresh vegetables, fruits; a constant 
avoidance of fatigue, either mental or bodily, remaining long 
in hot situations, &c. are the preventive means on which we 
must in a great measure rely. 

A prolonged immersion of the legs in hot water, to which 
two ounces of nitro-muriatic acid has been added, to each ten 
quarts of water, has been recommended; this means may be 
employed as a useful auxiliary. 

Finally, in those cases where the tubercles are very indo- 
lent, douches of vapour directed on the face, should be used, 
or even frictions or lotions, with some resolvent. 

Me nt agra. Sycosis menti. 

This disease corresponds with the first variety of the fifth 
species of Alibert, Dartre pustuleuse. First variety — Dar- 
tre pustuleuse mentagre. 

Mentagra is characterized by the successive eruption of 
small, acuminated pustules, somewhat similar to those of acne, 
on the chin, sub-maxillary and lateral parts of the face. It is 
essentially pustular, and this character is easily recognisable; 
it has nevertheless been mistaken by several English writers, 
as Willan, Bateman, and Plumbe, who regard tubercles as its 



192 PUSTULAR DISEASES. 

primitive lesion. Alibert and Biett have shown that these 
are but consecutive, that they do not exist in all cases, and 
finally, that the disease always commences with pustules. 

Symptoms. — Mentagra usually occurs in adults, but is 
sometimes observed in elderly persons. It very seldom hap- 
pens, before it declares itself in a decided manner, that it has 
not been preceded, for some months, and often for some years, 
by small, partial eruptions, either on the upper lip, the chin, 
or on the lower jaw; the pustules soon disappear, and the 
scabs which succeed them, dry, and fall off in a few days. Af- 
terwards, the eruptions become more abundant, and attract 
the attention of patients; they occur in most cases, from the 
influence of some occasional cause, as excess in drink, &c. 
The appearance of pustules is almost always preceded by red- 
ness, and heat of the chin, with a painful sensation of tension; 
numerous red points soon are visible, which become pustular 
in about three days; these pustules are acuminated, and usu- 
ally distinct, but when they are assembled in groups, and 
their number is considerable, the upper lip, and a great part 
of the chin, are covered with small, prominent tumours, of 
different sizes, the centre of which is traversed by a hair, and 
containing a yellowish-white pus. The pustules remain in this 
state six or seven days, and give the physiognomy a peculiar 
aspect; they finish by breaking, and are soon covered with 
brownish scabs, but there is no flow of matter as in impetigo. 
The scabs insensibly detach themselves, and the disease ter- 
minates from the tenth to the fifteenth day, if a new eruption 
does not take place. Ordinarily, there is a succession of par- 
tial eruptions, and the skin becomes the seat of a chronic erup- 
tion, either confined to certain spots, or extended over a large 
surface; the skin on which the pustules are situated with the 
subjacent cellular tissue, inflames deeply, there is then much 
heat, violent pain, and the scabs are sometimes thick. 

The extent of the eruption is variable; it is sometimes con- 
fined to the upper lip, at other times, to one side of the chin; 
in some cases, it only occupies a portion of the lower jaw, at 
other times, the lateral parts of the face are affected, and final- 






MENTAGRA. 193 

ly, the whole of these points may be simultaneously attacked. 
Oftentimes, the eruption does not appear at once, but several 
pustules are developed, disappear, and are followed by others 
for an indefinite period. In such case, the skin becomes rough, 
the cuticle throws off small, white exfoliations, in the middle 
of which may be seen new pustules. 

In many instances, the inflammation is far from being de- 
cided, resolution takes place but imperfectly, and tubercular 
swellings occur. This form of the disease especially affects 
persons who are feeble, the aged, and those who, though appa- 
rently strong and robust, have an injured constitution. These 
chronic engorgements present a multitude of varieties; they 
are sometimes as large as a cherry; in some cases, notwith- 
standing the existence of tubercles, the inflammation becomes 
violent; when this happens, the pustules, scabs, and tubercles, 
occupy the whole lower part of the face, which, from the 
swelling, becomes quite prominent; the eruption may also be 
found in all parts of the body that are furnished with hair, not 
excepting the eyebrows. Pustules are often developed on 
these tubercles; but it is incorrect to state, as has been done 
by Plumbe, that the centre of each tubercle contains a puru- 
lent matter. In some cases, the inflammation may be very 
severe in one spot, and extend to the cellular tissue, produc- 
ing phlegmonous inflammation. 

When the disease has existed for a long time, the bulbs of 
the hair participate in the inflammation, and it is easily de- 
tached; sometimes even spaces occur where it has been en- 
tirely destroyed, though it may reappear after a lapse of time, 
at first, light coloured and weak, but gradually regaining its 
natural hue and consistency. 

When the disease terminates, either naturally, or from me- 
dical treatment, the tubercles gradually diminish, the scabs fall 
off, the pustules only appear here and there; the spots which 
were the seat of the disease, remain red or purplish, and slight 
epidermic exfoliations take place for some time. At times, 
mentagra is confined to the middle of the upper lip, and seve- 
ral pustules aggregated on this spot occasion a thick, blackish 



194 PUSTULAR DISEASES. 

scab, forming a remarkable prominence, ( Dartre pustuleuse 
labiate, Al. ) But the varieties of mentagra are very numer- 
ous, and at the same time it would be useless to attempt to 
designate them. 

The duration of this disease is exceedingly variable; in some 
persons it will continue for an indefinite time, in spite of the 
most judicious treatment. It is also very apt to return, par- 
ticularly in those who live freely. 

Causes. — Mentagra particularly attacks young persons and 
adults; those who are of a sanguine and bilious temperament, 
and those who have much beard. Climate appears to exercise 
but little influence on its development; it is most frequently 
observed in the spring or autumn, or rather it makes its ap- 
pearance at these times, and continues through the other sea- 
sons. Those who are much exposed to the action of heat, as 
cooks, founders, blacksmiths, &c. are very liable to it, especially 
if they are habitual drunkards. It often occurs in persons in a 
state of extreme poverty and uncleanliness, or addicted to all 
kinds of debauchery; nevertheless, it also manifests itself in 
persons in an elevated rank in society, and who neglect no 
means of cleanliness. Patients generally attribute the appear- 
ance of the disease to the use of a dull razor, but, as M. Biett 
justly observes, this is only an excuse of self-love, which would 
rather assign any external cause, than to avow that a particular 
condition of their system had any influence on its appearance. 
But, if the eruption is once developed, the action of a razor 
certainly augments the inflammation. Mentagra very rarely 
occurs in females. 

Diagnosis. — The differential diagnosis of mentagra is very 
important, and has been perfectly treated on by M. Biett; it 
is highly necessary to distinguish it from the different erup- 
tions that may appear on the chin, and particularly from Im- 
petigo jigurata and the syphitides, whether they are pustular 
or tubercular. 

The pustules of ecthyma are larger than those of mentagra, 
and their base is more inflamed; the scabs of this disease are 
also larger, thicker, and more adherent; besides, it is never ac- 



MENTAGRA. 195 

companied with circumscribed indurations of the skin, or sub- 
cutaneous cellular membrane. 

In Impetigo Jigurata the pustules are flat, and hardly ele- 
vated above the level of the skin; they are disposed in groups, 
and their march is acute ; in mentagra the pustules are more 
or less acuminated and prominent; they are generally isolated 
and distinct. In impetigo the pustules break the third or fourth 
day, and discharge a fluid which promptly dries, and forms 
large thick pustules of a shining yellow colour. In mentagra 
the pustules do not break until the fifth or seventh day after 
their appearance; the scabs which replace them are of a deep 
brown, much thinner, and drier than those of impetigo, and 
finally, in this latter affection there are no tubercles, as in 
mentagra. 

It may be difficult to distinguish all these symptoms when 
the eruption is very extensive, the inflammation violent, and 
the pustules confluent; it is therefore often necessary, in these 
cases, to suspend our judgment, and wait the progress of the 
disease. 

Syphilitic pustules differ from those of mentagra, by the 
absence of heat, pain, and tension; they are flat, rise from a 
livid, or coppery base, and their progress is much slower. The 
pustules of mentagra are pointed, and their base is of a vivid 
red ; besides it is seldom that syphilitic pustules appear on 
the lower part of the face only; they are almost always to be 
found on the alae of the nose, on the forehead and angles of 
the lips. 

Syvhilitic tubercles differ from the chronic indurations that 
succeed the pustules in mentagra, in being shining, of a dull 
copper colour, and only appear to affect the superficial layers 
of the dermis ; whilst on the contrary, the tubercles of menta- 
gra are conoidal, and their base is implanted deeply in the 
skin; finally, the venereal eruptions are in most cases followed 
by scars, and are accompanied with pains in the bones, inflam- 
mations of the throat, &c. 

Mentagra can scarcely be mistaken for furunculi, which 
have a core, and leave small scars. 



196 PUSTULAR DISEASES. 

Prognosis. — Mentagra never occasions death, but caution 
should be used in giving an opinion as to its duration. Ac- 
cording to the frequency and succession of the eruptions, will 
the disease be prolonged. 

Treatment. — In the treatment of mentagra, the first indi- 
cation to be fulfilled, is to remove all causes that appear to 
exert any influence on the development of the disease, espe- 
cially if it affects persons who are addicted to drink, or those 
who are, from the nature of their professions, exposed to the 
heat of fire; every thing that tends to keep up or aggravate the 
disease, must also be forbidden; thus the patient must avoid 
shaving, and cut his beard with scissors. 

When the eruption is abundant, and the inflammation vio- 
lent, leeches should be applied several times, either behind 
the ears, or under the jaw. If the patient is strong and robust, 
a general bleeding may be ordered ; at the same time emollient 
fomentations and cataplasms of potatoes or of crumb of bread, 
may be employed with advantage. Topical blood-letting, and 
especially emollients, ought not, however, to be merely confined 
to these acute cases. This treatment is also of great utility, 
where, notwithstanding the duration of the disease, and the 
presence of chronic indurations of the skin, there also ex- 
ists some inflammation; an antiphlogistic regimen, and cool- 
ing drinks should be employed as adjuvants. Laxatives are 
proper in all cases, except where there is a gastro-intestinal 
irritation; calomel in the dose of four grains, sulphate of pot- 
ash, soda, or magnesia in the dose of two drachms, or half an 
ounce to a pint of ptisan, are generally used ; they must be 
continued for a long time, at least till there is a marked change 
for the better. 

When the disease lasts for a certain time, the tubercles 
large, and the skin and subcutaneous cellular tissue offering 
chronic engorgements of different sizes, it is in vain to make 
use of emollients; recourse must be had to other means; as 
frictions, made with an ointment of the ammoniacal proto- 
chloride, or of the deutoxide or sub-sulphate of mercury, in 
the proportion of 9i. to 5i- to axunge §i. 



PORRIGO. 197 

To these means may be added, with great advantage, the 
use of vapour baths, douches of sulphurous acid gas or of 
simple steam. Under the influence of these, and particularly 
of the last, the circulation becomes more active, the diseased 
parts, become bathed in sweat, and the tubercles often disap- 
pear with astonishing rapidity. We have seen these happy 
effects produced at the Hospital of St. Louis in a multitude of 
instances. 

If the eruption reappears to some extent, the use of fric- 
tions is to be suspended, but no attention is to be paid to a few 
scattered pustules. 

Cauterizations with either the nitrate of silver or concen- 
trated acids, ought not to be employed, except in cases where 
the disease has become entirely chronic; still they must be 
used with great precaution. 

Finally, under certain circumstances, where all rational 
means have failed, we have observed, at the Hospital of St. 
Louis, treatment of a very different character followed with suc- 
cess; thus we have seen patients cured by the use of tonics, con- 
sisting of the ferruginous preparations; in others the muriate of 
gold has been productive of good effects; M. Biett adminis- 
ters it in the dose of two-sixths and afterwards three-sixths of 
a grain, by frictions on the tongue. The mercurial prepara- 
tions taken internally, and particularly the Strop de Larrey, 
have been followed by beneficial consequences. 

Porrigo. Tinea. Les teignes. 

The older writers characterized the genus porrigo as ulce- 
rations attacking the scalp and destroying the hair; others re- 
garded it as constituted of the scaly affections; modern authors, 
however, have observed that the ulcers were usually preced- 
ed by pustules. 

Hence they have designated under the generic name of por- 
rigo or teignes, eruptions of psydracious pustules, generally 
contagious, and which are seated on the scalp, but may extend 
to other parts of the body. According to the characters as- 

26 



198 PUSTULAR DISEASES. 

signed to the genus, the species have been extended or re- 
stricted. 

Alibert described five varieties under the generic name of Ti- 
nea: la teignefaveuse, la teigne granulee, la t eigne furfu- 
racee, la t eigne muqueuse, and a fifth, of which he was the first 
describer, la teigne amiantacee. Willan, under the name of 
porrigo, gives six species: P. larvalis, furfur ans, lupinosa, 
scutulata, decalvans, and favosa. As these two authors are 
most generally followed, it must be remarked that in their 
descriptions they have not always assigned the same name to 
the same species. 

The Porrigo favosa of Willan is very distinct from the 
Teignefaveuse of Alibert. By this term, the latter author 
means an eruption which is at first pustular, and is succeeded 
by scabs of a large size, of a beautiful yellow colour, some- 
times bordering on white, and depressed in their centre; this 
is the P. lupinosa, of the former, who, on the contrary, has 
given the name of favosa to a pustular affection, promptly fol- 
lowed by thick scabs of a yellowish-brown, similar to those 
of Impetigo, or Porrigo larvalis; it appears to be only a va- 
riety of this last. The P. favosa we shall describe, is that of 
Alibert. 

The P. scutulata, or Teigne annulaire, known in England 
by the name of ringworm, is characterized by the develop- 
ment of pustules analogous to those of P. favosa, but assem- 
bled and grouped in such a manner as to form circular patches. 
Bateman considers the P. scutulata as having achores as its 
elementary lesion; but from a great number of facts, observed 
with the most scrupulous attention, M. Biett has been led to 
the conclusion, that it was, on the contrary, constituted of 
favi, that is to say, of pustules analogous to those of P. favosa, 
from which it is only to be distinguished by the arrangement 
of these pustules, and, at a more advanced stage, by a certain 
difference in the state of the scabs. It is a common occurrence, 
and we have several times observed it, for the original lesion 
to reappear, after the falling off of the scabs of the P. scutulata, 
and thus giving an opportunity of seeing that they were favose 



PORRIGO. 199 

pustules, so distinct from achores, that they could not be mis- 
taken for an instant. 

Porrigo larvalis, thus denominated because the features of 
the face are often hid under thick crusts, is the same affection 
described by Alibert as the Teigne muqueuse; the P. favosa 
of Willan, is also analogous to this, its nature being equally 
pustular. 

Porrigo granulata, Teigne granulee, is also a pustular 
eruption of the scalp, which gives rise to irregular, rough, 
gray, or brownish scabs, which occur in considerable quanti- 
ties among the hair, and detach themselves in spots, in the 
form of small, grayish, dry, hard granulations. This affection 
is not, as has been supposed by Bateman and Plumbe, a variety 
of P. scutulata, it rather resembles P. larvalis, which itself 
appears to be an impetigo. 

Porrigo furfur ans, or Teigne furfur ace" e, to which Ali- 
bert has assigned the presence of scales, as a specific character, 
appears, in some circumstances, to be Pytiriasis capitis, but 
in general, it is evidently a chronic eczema, and the scales re- 
sult from the desiccation of a fluid which is slowly effused 
from the surface of the scalp. When this is very abundant, 
the hair becomes united together, and presents a grayish, 
silky, and chatoyant lustre: this constitutes the Teigne ami- 
antace'e of Alibert. 

Finally, the partial baldness described by Willan under the 
name of P. decalvans, ought not to be considered as a distinct 
species, as it often results from the others. 

From what we have said, in order to dissipate any obscurity 
that might rest on this subject, it is easy to perceive that dis- 
eases which present marked differences, and some of which 
evidently belong to affections already described, have been ar- 
ranged under one common head. 

The pustules and scabs in the Teigne faveuse, those of the 
Teigne annulaire, and the rounded form of its patches, dis- 
tinguish these two species from all others; and they seem only 
to differ from each other by the arrangement of their pustules, 
and a certain condition of their scabs. They have a special 



200 PUSTULAR DISEASES. 

character, their contagious nature, which, however, does not 
appear to be constant. In these two diseases, the hair is soon de- 
tached in the affected spots, which has occasioned Underwood, 
Luxmore, and Duncan to think that in P. favosa, the seat of 
the disease was in the bulbs of the hair; they are readily dis- 
tinguished from other cutaneous eruptions. 

The Porrigo granulata, and larvalis, are closely allied, 
and are perhaps only varieties of Impetigo, or Eczema impe- 
tiginodes. The characters of the scabs in P. granulata, will 
no doubt suffice to distinguish it, notwithstanding the resem- 
blance of the primitive eruptions, but these characters are only 
well marked when the scabs have existed for some time. 

As to Porrigo furfur arts and the Teigne amiantacee, they 
are evidently chronic Eczemas, and they occur with all the 
characters of vesicular affections. If species must be made, 
M. Biett is of opinion that they must be reduced to two, Por- 
rigo favosa and scutulata. In fact, these two species alone, 
present characters which are not to be found in other orders. 
But although persuaded of the utility of this reform, yet not 
to swerve too much, in an elementary treatise, from establish- 
ed methods, and from the fear of passing lightly over two af- 
fections of such frequent occurrence, we shall describe both the 
granulata and the larvalis, although, we again repeat it, they 
belong in every respect to the impetiginous eruptions. 

But we entirely reject Porrigo fur fur arts and the Teigne 
amiantacee as belonging to Eczema; they are vesicular affec- 
tions, and consequently cannot be included in a genus the pri- 
mary character of which is a pustule. 

These different species scarcely ever exist simultaneously. 
They may attack all ages, and both sexes, but are most com- 
mon in infancy. They appear, in most cases, to be connected 
with a peculiar state of the system, but in some instances, un- 
cleanliness, misery, bad food, and deep grief, have either sepa- 1 
rately or collectively had a manifest influence on their deve-| 
lopment. At other times, they are produced by contagion, 
arising from a direct infection. The most common variety! 
is Porrigo favosa, and after that, Po?*rigo scutulata. 



PORRIGO. 201 

The treatment has often been, and sometimes is still -empi- 
rical; as the same remedy is frequently applied to entirely dif- 
ferent diseases, and the most simple varieties are treated in the 
same manner as the most violent, and we every day see the 
reputed means of cure for these eruptions applied to affec- 
tions of another nature; this explains those prompt and mar- 
vellous cures, which would otherwise astonish those who have 
seen all the varieties of porrigo, resist the best regulated 
treatment. 

Varieties. 

Two kinds of pustules occur in this genus — 1. Favi, which 
appertain exclusively to Porrigo favosa and scutulata.-— 
2. ^chores, which constitute Porrigo granulata and lar~ 
valis. 

It may be useful to establish the characters of these different 
constituents. 

1st. The Favi are small, circular, and inserted, as it were, in 
the epidermis, containing a fluid which rapidly concretes, and 
forms a straw-yellow substance, presenting a central depres- 
sion, which, by the aid of a microscope, can also be distin- 
guished in the commencing pustule. At the end of some days, 
this matter being constantly increased, forms a thick cellular 
scab, more or less prominent, which augments in size for a 
long time, at one moment presenting cup-like depressions, and 
at others losing this character, and appearing as thick crusts of a 
yellowish-gray colour, and very hard. 

2d. The Jichores are generally somewhat larger, are always 
superficial, having an inflamed base, are more or less irregular, 
confluent, and formed by the collection of a purulent fluid 
which raises the epidermis. At the end of some days, the 
pustules break and discharge a fluid which concretes and forms 
large yellowish or brown crusts, made up of layers, very dif- 
ferent from the thick incrustations that succeed to the favi. 
The achores which Willan and Bateman admit as varieties of 
pustules, differ but little from the psydracious pustules of 
impetigo. 



202 PUSTULAR DISEASES. 



Varieties whose elementary constituents consist of Favi. 
A. Porrigo Favosa. Teigne faveuse. P. lupinosa, Will. 

Porrigo favosa is characterized by an eruption of very small, 
flat pustules, which rapidly dry and appear to remain glued 
to the epidermis for a long time, forming small, very adherent 
scabs, of a bright yellow colour, and cup-like form. These 
scabs increase in size, preserving their central depression and 
circular form, if they should not be complicated with other 
affections; but even then the central pit is discernible. It is 
essentially contagious. 

The special seat of this disease is the scalp, but it may oc- 
cur on the forehead, the temples, the chin, and the eyelids; 
but in the majority of cases it primarily exists on the scalp, and 
extends from thence to the other parts. We have several 
times seen it at the Hospital of St. Louis, appearing on the 
shoulders, at the inferior part of the scapula, on the elbows, 
forearm, front of the knees, the external and upper part of the 
legs, the thighs, and if it attacks the body, the scrotum may 
also be implicated; it usually occurs on the back part of the 
body, though it can affect the abdomen. The hands may also 
be attacked, and in such cases, the disease arises from imme- 
diate contact. 

Symptoms. — P. favosa commences by extremely small 
psydracious pustules, which are scarcely perceptible on the 
first day. They appear in the form of small yellow points, 
and remain on a level with the surface, being as it were 
implanted in the epidermis. They have scarcely formed, be- 
fore the small quantity of yellowish matter they contain con- 
cretes, and there may be perceived, either with the naked 
eye, or by means of a magnifier, a minute central depression, 
which becomes more apparent, as the scabs augment in size, 
and is very evident at the end of five or six days. The pus- 
tules are generally distinct at the beginning; sometimes, on the 
contrary, they are grouped and multiplied to such a degree as 
to form a continuous surface. Their development is always 



TORRIGO, 203 

accompanied by itching in whatever situation they may occur: 
the skin that surrounds them is very red. When they are dis- 
tinct, their base is sometimes elevated and inflamed; in most 
cases, each pustule is traversed by a hair. 

The scabs slowly augment in size, preserving their circular 
form and central depression, which becomes more and more 
apparent; they may also acquire an extent of several lines, and 
M. Biett has seen them more than one inch in diameter. 
When the pustules are contiguous, these scabs become united 
at their edges, and thus form yellow incrustations of some 
size, and presenting a host of alveolar depressions, each of 
which corresponds to a former pustule. These pits have been 
happily compared by Alibert to the cells in a honey-comb, or 
the cups on the lichens which cover the trunks of certain 
trees. Sometimes a kind of scabby cap covers all the head ; 
at other times there is a slight epidermic desquamation in those 
parts on which there are no pustules. 

At this time the scabs are of a yellow or deep fawn colour, 
and if they are removed by means of emollient cataplasms, or 
by lotions, either of a simple nature or alkaline, slight erosions 
are found, which do not again become covered with a crust; 
to form these, a fresh eruption of pustules must take place. 
When the disease is left to itself, the scabs being very adhe- 
rent, remain attached for months or even years; but then they 
become thicker and white, and are accidentally broken and 
detached in spots. As the disease follows this course in one 
point, there are often other pustules formed in another, which 
pursue a similar march. 

When the scabs have existed for a long time, the skin be- 
comes the seat of a chronic inflammation, which is deep-seated 
and severe; and the layers of the dermis are successively in- 
volved. It sometimes reaches the lamellar tissue, or even the 
pericranium and bone. 

If the state of the hair be examined in persons affected with 
P. favosa, it will be found that it can be pulled out with the 
greatest ease, wherever the pustules are developed, at the very 
commencement of the eruption. At a later period the scalp 



204 PUSTULAR DISEASES. 

becomes bald, and the skin remains smooth and shining, 
wherever the hair is wanting. This is rarely restored, at least 
it never regains its original appearance, but presents, on the 
contrary, a woolly appearance that is very striking. 

Porrigo favosa is never accompanied with general symp- 
toms at its commencement, but the itching is sometimes very 
violent, and becomes more so from want of cleanliness, for in- 
stances often occur where lice exist in great numbers under 
the scabs. This causes the patients to scratch, which tears the 
scabs, and increases the inflammation. In such cases, the head 
exhales a very disagreeable odour, which resembles, as has 
been remarked by Alibert, that of the urine of a cat. 

It should be remarked, that when the head is cleansed from 
the scabs and insects, the smell becomes heavy and sickening. 
The excoriations which occur on the surface of the dermis, do 
not produce scabs with a depressed centre, but there flows from 
them a fetid and reddish pus, which forms irregular crusts, 
but new eruptions soon appear, which give rise to fresh favose 
scabs. 

This disease may determine small subcutaneous abscesses; 
the lymphatic ganglions of the neck are often sympathetically 
swelled, but it rarely happens that this eruption is complicated 
with inflammation of any of the internal organs. It must be 
observed, that those individuals who are attacked with it, 
often remain small and diminutive; their intellect is usually 
weak. 

The seat of the favose pustules has been placed in the reti- 
cular tissue by most pathologists. Duncan says, that it is in 
the bulbs of the hair, and in fact, in almost all cases, it is very 
easy to pull out both the hair and its bulb, wherever the pus- 
tules are formed ; they seem as if they were fixed in a soft sub- 
stance. This is not only observed when the disease is of long 
standing, but also in all points where new pustules arise; if the 
extracted hair be examined with a microscope, a small swell- 
ing may be perceived, but the enlargement of its base, by 
which it is attached to the dermis, is wanting. 

The duration of this affection is indefinite; it is impossible 



PORRIGO. 205 

to fix a term to it. When a cure takes place, and no new 
eruptions occur, the scabs fall off, the subjacent surfaces dry, 
and a reddish spot remains. It is seldom that the hair reap- 
pears with its normal characters, but we have seen, among 
others in the wards of M. Biett, a man, in whom they had 
been renewed, to all appearance, precisely similar to those that 
had been destroyed. 

Causes. — P. favosa is evidently contagious; in some cases, 
however, it has been attempted in vain to provoke the disease. 
It is developed at all seasons; it attacks both sexes indiffer- 
ently, as well as all ages, though it is usually seen in children 
and young persons. Various circumstances, which act by de- 
teriorating the constitution, appear to assist in its develop- 
ment, such as the want of proper food, misery, and uncleanli- 
ness, a lengthened residence in unhealthy, humid, and low 
situations, such as prisons, &c. It is also observed in persons 
of a lax, lymphatic, and scrofulous constitution. 

Diagnosis. — The presence of small, yellow pustules, im- 
bedded in the epidermis, the existence of yellow, dry scabs, 
which are cup-shaped, are characters which are sufficiently dis- 
tinct to prevent this disease from being confounded, not only 
with other eruptions, but also with the other species of por- 
rigo. At the same time, it does not differ from P. scutulata 
except in the disposition of the pustules, which are usually 
distinct in the P. favosa, whilst they are grouped in the P. 
scutulata. When many scabs exist, they are then of a whitish- 
yellow, dry, and sometimes breaking into powder; in this 
case they somewhat resemble those of P. granulata, but in 
general, the scabs of the disease under consideration, preserve 
their distinctive characters, added to which, the hair is almost 
always destroyed on the spots occupied by the disease, when 
it is thus of long standing, which never takes place in P. gra- 
nutata. 

It is almost needless to attempt to describe the differences 
which may exist between the eruptions of other genera and 
this disease, as its characters are so prominent that they will 
always be recognised. At the same time we have seen a phy- 

21 



206 PUSTULAR DISEASES. 

sician, who, from his situation, would have been supposed to 
be acquainted with diseases, which daily came under his no- 
tice, confound a case oifavus, which occupied a large portion 
of the surface, with lepra. But such errors can be but seldom 
committed, even by the merest tyro. 

Pi^ogiiosis. — The prognosis is unfavourable from the dura- 
tion of the disease; it is the more so, when fresh eruptions 
constantly appear on the first being healed. 

Treatment.-^ There is perhaps no disease for which so 
many remedies have been proposed, as P. favosa, and in ge- 
neral, each of these was infallible, if we were to believe its pro- 
jector. Nevertheless, whatever means may be employed the re- 
sult is but too often unsuccessful. The treatment is all external. 
In some cases only, it is advantageous to support the strength 
of the patient by the use of bitters, and in some instances also, 
recourse may be had to mild laxatives with advantage. 

But the first thing in the treatment is cleanliness; the hair 
is to be cut very short, or what is better, shaved off, the scabs 
are to be detached, and the surface washed with an emollient de- 
coction, which is to be alternated with the use of soap and water. 
These means, simple as they may appear, are auxiliaries which 
are useful, and indeed indispensable in the generality of cases; 
it is to them that should be attributed certain cures of which 
the credit has been given to some useless remedy, to blisters on 
the arm, for instance, a method of treatment which is of very an- 
cient date, as it is described in Vandermonde's Journal of Me- 
dicine. 

In a great majority of cases, these means will not suffice; it 
becomes necessary to modify the state of the skin by more 
energetic applications. The cap has fortunately been aban- 
doned for some time, and we can scarcely credit, that igno- 
rance would now dare to make use of so cruel a method; be- 
sides, it only appears to act by the evulsion of the hair, which 
always attended its employment. Is the presence of the hair 
as prejudicial as some authors insist? and when it falls off from 
the effects of the disease, does this disappear? On the con- 
trary, the scabs often remain for years on places where there 



PORRIGO. 207 

is no hair; besides, its extraction, by means of small forceps, 
but only on the diseased spots, is not as painful as might be 
supposed. In fact, the hair has very little attachment at these 
spots; but it can be destroyed by much milder means, the 
alkaline preparations fulfil this end very well, and, at the same 
time, which is not less essential, they very advantageously 
modify the morbid state of the skin. The remedies on which 
reliance ought to be placed, in addition to cleanliness, are the 
alkaline and sulphurous preparations, and acidulated lotions. . 

The alkaline preparations which should be used, present 
many differences, according to the action that is wished to be 
produced; when it is wished to destroy the hair, and at the 
same time make some impression on the scalp, the subcar- 
bonate of potash or soda, mixed with axunge, in the propor- 
tion of one or two drachms to the ounce, and rubbed on the 
diseased spots for five or ten minutes each day, will in a short 
time detach the hair; mild alkaline lotions, made by adding two 
drachms of these salts to a pint of water, may be employed at 
the same time. Before beginning their use the hair must be 
cut off, and large emollient cataplasms applied, as well as lo- 
tions with warm soap and water, in order to detach the scabs 
and cleanse the surface. 

At the Hospital of St. Louis, we have several times seen the 
sulphuret of potash used with much advantage, in the propor- 
tion of one or two drachms to a pint of distilled water, or 
what was still better, the following lotion, (called Barlow's,) 
sulphuret potassae, 3\j- sapon alb. 5iiss. aqua calc. §vij. spt. 
vin. rect. 3i. Finally, in some cases, the patients were much 
benefited by the use of the chloride of lime.* 

* Barlow's lotion, as given by Burns, in his midwifery, differs from the 
above in its proportions, being as follows: R kali sulph. giij. sap. alb. giss. 
aqua calcis, ^viiss. spt. vini. ^ij. M. — He also observes, that Underwood 
recommends the decoction of tobacco, or lotio sapon; Dr. Franck, urine, 
and Heberden, a decoction of white hellebore. 

Heberden also agrees with our text in remarking that he has found little 
benefit from internal remedies. Burns, however, thinks that he has derived 
advantage from the use of a decoction of the woods, sulphur, and small 
doses of calomel. — Trans. 



208 PUSTULAR DISEASES. 

Mild sulphurous douches, repeated every day, will be of 
great service; they, as well as the lotions, prevent the oint- 
ment that has been used from remaining too long in contact 
with the skin. The physician must have great patience, and 
see that his orders are fully complied with. The remedies of 
the Mahons, are, (it has been ascertained,) composed of alka- 
line preparations, and the precaution they take of conducting 
the treatment with their own hands, ought not to be overlook- 
ed, as a cause of the numerous cures they have obtained. We 
are far from wishing to dispute their success, but there can be 
little doubt that it would be much less, if they reduced the 
number of diseases to the tineas, properly speaking, (P. fa- 
vosa and scutulata,) and we think that these two varieties, 
which we have so often seen resist the best regulated treat- 
ment, will also prove as refractory under their plan of cure, as 
under the various methods made use of, at the Hospital of St. 
Louis. 

Some acids, much diluted, such as the muriatic and the ni- 
tric, have been employed with success in some cases; these 
acidulated lotions may be replaced with advantage by those of 
the hydrocyanic acid, in the proportion of a drachm to each 
pint of distilled water. 

The other means that have been employed by different prac- 
titioners with success, are solutions of the sulphates of zinc 
and copper, nitrate of silver, in the proportion of three to six 
grains to the ounce of distilled water; or, finally, corrosive 
sublimate, in the same proportions. To these solutions, two 
or three ounces of alcohol to the pint of water, may be added. 

Those ointments which have been the most praised, are sulph. 
sublim. mixed with axunge, in the proportion of 3ij- to the 
ounce, and as much white soap; calomel, 3ij. axunge, §i. ox- 
ide of manganese in the same proportions; and, finally, Ban- 
yer's ointment, litharge, §ij. calcined alum, giss. calomel, 
§iss. axunge, fbij. Venice turpentine, fbss. But of these re- 
medies, the most prompt and successful certainly is the iodu- 
ret of sulphur, latterly employed by M. Biett, and applied by 
him to the cure of these diseases. We have seen, in a few 



PORR1GO. 209 

weeks only, this remedy modify the morbid action of the 
skin, under its influence the pustules ceased to appear, and it 
was during its use that we have seen the hair reappear of its 
natural consistency and colour. The diseased parts are to be 
lightly rubbed, night and morning, with the following oint- 
ment, ioduret of sulphur, 9i. to 3ss. axunge, §i. 

In the use of all these means, great care must be taken to 
detach the scabs as fast as they form, by the aid of emollient 
or alkaline lotions perseveringly applied. But, M. Biett com- 
menced, some time since, a series of experiments, not only on 
the methods of cure already known, but also on many sub- 
stances which have been recently introduced in the materia 
medica. The results of these experiments still presenting 
some uncertainty on many essential points, M. Biett has 
thought proper to postpone their publication. 

Baths are always useful, and should be prescribed from 
time to time, particularly where the disease is on the body 
or limbs. Sulphurous baths are very advantageous in some 
cases. 

When the disease is local, and only consists of some pus- 
tules scattered here and there, after removing the scabs, the 
surface may be cauterized with nitrate of silver. Cauteriza- 
tion has also been proposed and employed with success in some 
very obstinate cases, and to accomplish it, the concentrated 
acids have been used, as the nitric, sulphuric, hydrochloric 
and acetic; in employing them, after the scabs have been re- 
moved, and the diseased surface perfectly cleansed, the end of 
a quill dipped in one of these acids is to be passed over the 
eruption, and before the caustic has had time to extend its ac- 
tion too far, the parts are to be washed with cold water. Se- 
tons, blisters, and issues, are less useful than has been supposed. 
Finally, in the treatment of this affection, it should never be 
forgotten, that a single remedy is far from being always suc- 
cessful, that much perseverance is necessary, as well on the 
part of the physician as on that of the patient, and that in all 
cases, whether successful or not, cleanliness is sedulously to be 
attended to. 



210 PUSTULAR DISEASES, 



B. Porrigo Scutulata. Teigne annulaire. Ringworm of 
the Scalp. 

Porrigo scutulata is a chronic inflammation of the scalp, 
characterized by favose pustules, not isolated and distinct, as 
in P. favosa, but united in groups, and so disposed as to form 
circles, at the circumference of which these small, yellow pus- 
tules are in greater numbers than in the centre; they are foh- 
lowed by scabs, which, though thin at first, often become very 
thick; and by the aggregation of the favi, constitute incrusta- 
tions of a large size. This eruption is essentially contagious. 

P. scutulata particularly appears on the scalp, which is its 
special seat; but it may exist at the same time on the forehead 
and neck. When it is observed on other parts of the body, 
which is but rarely, it is generally produced by a direct con- 
tagion. 

Symptoms.- — This disease commences by red, circular 
spots, on which very small, yellow pustules may soon be per- 
ceived. These do not rise above the level of the skin, and 
appear to be set in the epidermis. These pustules are group- 
ed, and are much more numerous towards the circumference 
of the patch than in the centre; violent itching accompanies 
their formation, and that of the erythematous spots which 
precede them. The pustules of this variety are absolutely 
similar to those of P. favosa, though perhaps not of as bright 
a yellow; like them, they have a central depression, are ge- 
nerally traversed by a hair, and they dry quite as quickly. 
They first form thin scabs, which gradually augment, and be- 
come more prominent; and if they are permitted to accumulate, 
they unite and constitute large incrustations, generally circum- 
scribed by a circular line. If they fall off, or are detached by 
emollient applications, the skin is found red, shining and in- 
flamed; other analogous pustules soon appear and follow the 
same course. This eruption particularly takes place at the 
circumference of the former, which gradually extends, and 
may even acquire a diameter of two inches. 



PORRIGO. 211 

From the commencement, it will be perceived that the hair 
which covers these spots, has become thinner, dry, and wool- 
ly, and the slightest effort will detach it; it is evident that the 
bulbs are affected very soon after the appearance of the dis- 
ease. It is finally destroyed as the eruption advances. 

In most cases, when the disease has lasted some time, the 
other parts of the scalp which are not affected with the erup- 
tion, become the seat of a slight epidermic exfoliation. When 
the circular patches are numerous, either from being sponta- 
neously developed, or from the patient inoculating other spots 
by scratching, they may extend and unite; these confluent 
pustules form scabs of great thickness, and in some cases, 
the incrustation may cover the whole scalp. The patient then 
presents a remarkable appearance, especially if the disease is 
of long standing; his head is occupied by a kind of thick cap, 
whose circumference presents evident marks of the original 
form of the disease. Thus, quarter and half circles are dis- 
tinctly seen, and no hair is found, except at the junction of the 
scalp with the skin of the face; above this kind of crown, 
formed by thin and woolly hair, is to be perceived a crusta- 
ceous covering of a grayish-yellow, which does not, like P. 
favosa, present central cup-like depressions, but dry, friable 
scales, which fall off in small portions, and resemble mortar, 
coarsely broken, or plaster fallen from a wall, and sullied by 
dust and moisture. Sometimes the disease in this state, in- 
stead of occupying all the head, is confined to one or more 
spots; and the eruption may be seen in all its stages. Thus, 
patches of a vivid red may be perceived, especially at the cir- 
cumference, then a greater or less number of yellow pustules 
at a little distance, thick scabs, and finally, white spots, en- 
tirely deprived of hair, and near them, slightly inflamed 
points, which are the seat of an epidermic exfoliation. 

The disease may remain in this state for an indefinite period ; 
it may last for months, but at last, either spontaneously, 
(which is rare,) or from the effect of medical treatment, the 
seabs fall off, the surfaces they leave exposed, become less in- 
flamed, the eruptions take place less frequently and numer- 



212 PUSTULAR DISEASES. 

ously, the scabs are not as thick; they gradually cease to form, 
and the disease disappears, leaving places of various sizes, on 
which the hair remains for a long time, thin, soft, and disco- 
loured, and even in some cases, never reappears. 

Causes. — When this affection is spontaneously developed, 
it is only observed in children, in individuals of a lymphatic 
temperament, badly nourished and clothed; but it is usually 
propagated by contact; the use of the same towels, combs or 
caps, may occasion it; it is also observed, but less frequently, 
in adults. 

Diagnosis. — The diagnosis of this eruption may present 
some difficulties in certain cases. P. favosa is the only spe- 
cies of porrigo with which it can be confounded. It differs, 
in fact, from the others, in a marked manner, by the nature of 
its pustules, (favi,) by the colour and form of the scabs, by 
the baldness they occasion, and finally, by its contagious cha- 
racter. 

As to P. favosa, the P. scutulata has the same elementary 
lesions; small, yellow pustules imbedded in the epidermis, 
and depressed at their centre; but here they are grouped, and 
form by their union, distinct circles, characters which are not 
found in the former, the distinct pustules of which never unite 
so as to form a regular figure. Nevertheless, in cases where 
the scabs of P. scutulata cover almost the whole of the scalp, 
they may be confounded with the thick crusts of P. favosa, 
which also form a kind of cap which is spread over the whole 
of the head, but the scabs of the latter, when examined with 
attention, present here and there some points, where the cup- 
like depressions may be found, and besides these large incrus- 
tations are never circumscribed by regular lines, whilst those 
of P. scutulata always have portions of circles at their edges, 
indicating the original form of the eruption, and finally, in 
this latter disease, the cup-like pits are never to be seen; but 
instead of them, fragments of scabs resembling broken mortar. 

Impetigo fgurata may also be mistaken for this disease, 
when it is seated in the scalp, or else the P. scutulata mayl 
be confounded with the former if it is developed on the limbs:! 



PORRIGO. 213 

in fact, Impetigo Jigurata is characterized by a union of pus- 
tules, giving rise to thick scabs, regularly circumscribed, and 
often perfectly round; but these two diseases present very 
great differences, both in their pustular and their crustaceous 
state. In the first, the superficial and slightly prominent pus- 
tules, arising from a red and highly inflamed surface, which 
characterize Impetigo, cannot be confounded with those of 
Porrigo, which are deeper seated, and imbedded in the epi- 
dermis, are only accompanied by a very slight inflammation 
at their base, and finally present a concrete matter almost from 
the period of their formation, whilst the psydracious pustules 
of Impetigo contain a liquid which gradually thickens and re- 
quires some days to form a true scab. In the crustaceous 
state, the differences are less marked; the scabs of Impe- 
tigo are thinner; when they fall off, they are replaced by a 
sero-purulent effusion, whilst it requires fresh pustules in 
Porrigo to give rise to new incrustations; besides, the former 
is always confined to small spots; its patches are often distinct, 
and the latter, when in this state, is easily recognised; its 
crusts being thicker at the circumference than in the centre, 
whilst the contrary is the case in Impetigo. 

Besides, if it be remembered, that Impetigo is not conta- 
gious, that, when it is seated in the scalp, it never occasions 
a loss of the hair, that on the other hand, the presence of Por- 
rigo scutulata on the limbs is extremely rare, and almost al- 
ways coincides with the same eruption developed on the scalp: 
we shall have characters sufficiently well marked, to prevent 
us from ever confounding these two affections, which it is 
very important to distinguish. 

The patches of Herpes circinnatus at their commencement, 
or of Lepra deprived of its scales, when seated on the scalp, 
may perhaps be taken for those of P. scutulata, when it 
is just beginning, and is only characterized by the small, red, 
circular spots, which precede the appearance of the pustules; 
it is almost useless to add, that the development of each of 
these diseases will present symptoms of sufficient distinct- 

2S 



214 PUSTULAR DISEASES. 

ness to prevent any doubt, and which will speedily correct 
any error. 

Prognosis. — P. scutulata is not serious of itself, but it may 
become so from its duration, and its obstinacy in resisting the 
different plans of treatment; nevertheless, it is generally less 
troublesome than P. favosa. 

Treatment. — The basis for the treatment of this disease, is 
generally the same as that for P. favosa, and as in that eruption 
internal remedies are of little benefit, so here, external means 
are to be relied on. Frequent lotions, with warm water 
or milk; cutting the hair very short, or even shaving it off, if 
this latter operation does not occasion inflammation; and emol- 
lient cataplasms, to disengage the scabs, are the only means 
to be employed at the commencement; at a later period, it be- 
comes necessary, as in the P. favosa, to modify the state of 
the diseased parts, and recourse may be had, (according to 
the violence of the disease,) to one or other of the remedies 
we pointed out, when speaking of the latter disease, as the 
sulphurous and alkaline preparations, Barlow's lotion, solu- 
tions of the sulphates of zinc and copper, or even of corrosive 
sublimate, with the addition of a certain quantity of alcohol. 
Frictions may be made with sulphurous or calomel ointments, 
but above all, if the disease is obstinate, with that of the iodu- 
ret of sulphur. Simple baths, sulphurous douches, and espe- 
cially cleanliness, are very efficacious. 

In fact, the same treatment is to be made use of, as we have 
indicated for P. favosa, under the head of which all these 
means are spoken of at large. 

B. Varieties in which the elementary lesions are composed 
of Achores. Porrigo Larvalis. Teigne muqueuse. 
Crusta lactea. Tinea muciflua. 

Porrigo larvalis is characterized by an eruption of super- 
ficial pustules of a yellowish-white colour, more or less con- 
fluent, united in groups, which are succeeded by yellow or 
greenish scabs, sometimes lamellar and thin, sometimes thick 



PORRIGO. 215 

and rough, and offering the greatest analogy to those of Ec- 
zema impetiginodes, or Impetigo Jigurata. 

This disease is particularly observable in children, and es- 
pecially in infants; it may be developed on all parts of the 
body, but those most subject to it, are the scalp, the ears, and 
lips; the face is often almost covered with thick scabs, which 
hide it like a mask, from whence is derived the name larvalis. 

P. larvalis offers many varieties which result from the de- 
gree of inflammation, and the greater or less thickness of the 
scabs. In very young children, the disease only consists in 
the appearance of small pustules, which are scattered over the 
scalp, temples, &c. and soon form thin scabs, but which some- 
times becomes thicker as the effusion increases; these are what 
authors have designated as the milky scall. In these cases, 
the affection is very mild, but it often is much more violent, 
and shows itself either on the face, scalp, or on both these places 
and different parts of the body at the same moment. 

On the face, the disease usually commences on the forehead 
or cheeks, by small pustules grouped on a surface of greater 
or less extent; violent itching accompanies their appearance; 
they soon open either spontaneously, or by the action of the 
nails, and a viscous, yellow fluid is effused, which forms thin, 
soft crusts of a yellowish-green colour; the effusion continues; 
new crusts form, the first augment in thickness, and are found 
thick, soft, and rounded in one place, whilst they are thin 
and lamellar at another. When they fall off, they leave a red 
surface, highly inflamed, upon which fresh crusts are formed : 
the effusion is sometimes so abundant, that the fluid does not 
concrete, so that the surface of the dermis is exposed, and a 
viscid, thin, and acrid fluid may be seen issuing from a multi- 
tude of small points. When the disease is of a certain extent, 
the itching and pain are often very violent; when it occupies 
the forehead, the cheeks, or the chin, all these parts are cover- 
ed with a large, thick crust, like a mask, the nose and eyelids 
alone usually appear to be exempt* 



* Mr. Christian, of the Liverpool Ophthalmic Infirmary, has described an 
inflammation of the eye, which he says is a very common attendant oner up- 



21 f) PUSTULAR DISEASES. 

In other cases, the pustules are larger, they develope them- 
selves behind the ears, around the mouth, and on the chin, 
soon giving rise to thick crusts of a greenish-yellow colour. 
Under some circumstances, the mouth is surrounded with 
large, thick, yellow incrustations, which are of a deep brown 
in certain spots, where a little blood has mixed with the dried 
fluid j in these instances the movements of the lips are much 
impeded: at other times, these large incrustations occur behind 
the ears. These crusts exhale a sickening odour; very often 
the adjoining lymphatic ganglions inflame, and may even sup- 
purate; sometimes the eyelids are the seat of a chronic inflam- 
mation, and there is often coryza, and an abundant flow of mu- 
cus from the nasal fossae. 

When the disease approaches a cure, the effusion diminishes, 
the crusts are formed more slowly and become thinner and 
whiter, the surface on which they rest, is less and less red, 
they are soon replaced by a slight desquamation, which also 
soon disappears, and there only remains a light rosy tint on the 
spots that were the seat of the disease, this also gradually fades 
away. Such is the usual termination of this variety; some- 
times, however, fissures occur, and, in some cases, at the mo- 
ment when all appears about to terminate, a new eruption 
is developed, and the disease recommences. It never causes 
cicatrices, and if they have sometimes been observed, they 
were evidently the result of scratching, as children, if great 
attention be not paid to them, will sometimes tear themselves 
to such a degree as to cause the flow of a considerable quan- 
tity of blood. 

When this affection attacks the scalp, the pustules are closely 
set, they are of a yellowish-white colour, and sometimes oc 
cupy the posterior portion of the head only, at others, all those 
parts that are covered with hair are affected, at times the pus 
tules are very small and intermingled with vesicles, the greater 
part of which become pustular, whilst others acquire a trans- 

tive diseases, and particularly of Porrigo larvalis and favosa, to which he ha 
given the name of porriginous ophthalmia. This appears principally to afiec 
children. — Trans. 



torrigo. 217 

parency; they are accompanied with great itching; they soon 
open, but are generally torn by scratching; they effuse a thick, 
viscous fluid, which glues the hair together, and in drying 
forms irregular scabs of a yellowish brown colour. These are 
sometimes scattered and sometimes confluent, and cover a con- 
siderable space, the effusion continues, and if the hair is long 
and there is a want of cleanliness, a great portion of the scalp 
is at last covered by a very thick, brownish crust, which in 
drying breaks into small friable portions, and finally presents 
all the characters which it will be seen are assigned to P. gra- 
nulata. When these incrustations are thick and extensive, 
and the patient keeps his head wrapped up in rags, which are 
suffered to remain for months, impregnated with the discharge, 
the odour is foetid and insupportable on their removal, and 
thousands of lice may be seen, which augment the pruritus 
and inflammation. 

On the contrary, when the scabs are removed with care, by 
means of emollient lotions, the surface is found but little in- 
flamed, and presenting slight excoriations, which secretes a vis- 
cid fluid of a heavy smell from a multitude of points; some- 
times the subcutaneous cellular tissue is inflamed in spots, and 
forms small, circumscribed, purulent abscesses, which rarely 
terminate by resolution, and are obliged to be opened. 

When the disease lasts for a long time, and the crusts have 
remained for months without any attempt to detach them, the 
hair falls off; but this baldness is totally different from that 
which constantly attends the two former varieties, being only 
accidental and temporary, the bulbs are not destroyed, but in- 
flamed, hence the hair soon reappears of the same colour and 
consistence of that which covers the sound parts. 

Not only the scalp, forehead, mastoid regions, and all the 
face may be more or less affected at the same moment, but 
the disease may also extend to the body and limbs; they ap- 
pear in this case to be smaller, and less confluent, the scabs 
which succeed them, thinner, and the disease is closely allied 
to Impetigo. 

The duration of this disease is very variable; although less 



218 PUSTULAR DISEASES. 

obstinate than the two former species, it may, notwithstand- 
ing, last for several months. 

Causes. — P. larvalis is never contagious, and is generally 
observed in children ; it appears about the period of the first 
or second dentition. The causes are difficult to ascertain, in 
a majority of cases; for if it occurs in the badly nourished and 
weak, it is also to be seen in the strong and healthy: want of 
cleanliness may have some influence on its appearance. This 
disease also affects adults. 

Diagnosis. — The characters heretofore assigned to P. fa- 
vosa and scutulata, are certainly so well marked that they 
can never be confounded with this disease. 

It is more difficult to draw a line of distinction between this 
affection and P. granulata, which is perhaps but a variety 
of the same species, particularly at its commencement; at a 
later period, the form of the scabs, which in the latter become 
dry, very hard, and grayish, is the only character by which 
they can be discriminated. 

It is still more perplexing, not to say impossible to distin- 
guish it from Impetigo or other eruptions of the same nature, 
such as Eczema impetiginodes; the same constituents, same 
appearances, same form of scabs, except that the seat being in 
the face and scalp, and the greater or less violence of the in- 
flammation, may make some slight difference. 

In describing the P. favosa of Willan, which is only a va- 
riety of P. larvalis, Bateman observes that the Dartre crus- 
tacee flavescente of Alibert, appears to be a P. favosa, situa- 
ted on the cheek; but this eruption being Impetigo figurat a, 
it is evident that the appearances of P. favosa of Willan are 
the same as those of Impetigo; and it is consequently clear, 
that Bateman, who admits that the P. larvalis is a variety of 
this eruption, also agrees that it is the same as that described 
by Willan under the name of P. favosa. Finally, Burns, in 
his work on the diseases of children, describes as identical dis- 
eases, those known under the name of Crust a lactea, Tinea 
muciflua, and P. larvalis, but offering varieties according 
to the violence of the inflammation: we repeat that it is im- 



PORRIGO. 219 

possible to establish the distinctive characters between this dis- 
ease and Impetigo, or Eczema impetiginodes. 

Prognosis. — The general health is seldom affected by this 
eruption; in some cases, however, gastro-intestinal irritations 
and diarrhoea supervene, and the children become attenuated. 
The prognosis of P. larvalis is usually favourable, and this af- 
fection is only fatal when it is accompanied or followed by 
some disease of important viscera. If the eruption has 
lasted for a long time, if it gives rise to a very abundant dis- 
charge, it is unfavourable, particularly when it thus occurs on 
a very young, weak, and debilitated infant, and in a condition 
where it cannot receive the proper attentions.* 

Treatment. — In the generality of cases, lotions of tepid 
water, milk, or decoction of mallows, which unite the double 
advantage of preventing the scabs from accumulating, and of 
calming the violence of the inflammation, should constitute 
the whole treatment; and in children at the breast, the best 
remedy is to direct the nurse to wash the diseased parts with 
her milk. When there is great itching and much irritation, 
recourse must be had to tepid emollient baths. It is often 
useful to change the milk of an infant, if it is possible, or at 
least to permit it to suck but seldom, feeding it on water 
gruel or barley water. 

As to blood-letting, it should not be employed, except in chil- 
dren who are from two to three years of age, and when there 
is much inflammation; a topical bleeding, by two leeches be- 
hind each ear, will fulfil the desired intention. The treat- 
ment is similar in young persons and adults, except that if the 
scalp or face is attacked with a violent irritation, general 
bleeding should be used, and leeches applied behind the ears, 
or on the mastoid apophyses. 

The hair should be cut very short when the disease occu- 

* Dr. Dewees, in his " Diseases of Children," states that he has seen two 
instances of death from this eruption; in these cases the itching was un- 
ceasing: the disease continued many months, till at last the children were 
destroyed by the pertinacity of the fever and the profuseness of the diarrhoea, 
Trans. 



pies the scalp, and emollient cataplasms of bread and milk, 
or potatoes and a decoction of mallows, applied to the part, and 
frequently renewed. When the eruption has lasted for some 
time, and is extensive, it becomes necessary to change the 
state of the skin; for which purpose, sulphuro-alkaline lotions, 
made by adding one drachm of sulphuret of potash and two 
drachms of subcarbonate of potash or soda to a pint of water, 
are very advantageous. These lotions and mild ointments 
should be used two or three times a day. 

Mild laxatives are sometimes useful; the syrup of chicory 
may be employed in very young children; in those who are 
older, in young persons and adults, calomel in the dose of two 
to four grains a day, the sulphate* of soda in the dose of two 
drachms, or half an ounce in a pint of barley water, &c. will 
sometimes produce happy results. 

Sulphurous douches may become useful, and when the dis- 
ease appears on the body and limbs, and is obstinate, sulphur- 
ous, alternated with tepid emollient baths, should be pre- 
scribed. Issues, and the application of blisters to the arm 
have also been advised, but their use only adds to the irrita- 
tion of the skin. 

In some rare cases, the appearance of P. larvalis has ap- 
peared to have acted beneficially, and to have tended to the 
cure of more dangerous diseases. Under these circumstances, 
and above all, when the abundance of the discharge appears to 
coincide with the disappearance of the first disease, the treat- 
ment must be undertaken with the greatest prudence, and it 
is often useful to confine it for some time to simple palliatives 
and cleanliness. 

Porrigo Granulata. Tinea granulata. P. lupinosa. 

Porrigo granulata is characterized by the presence of 
small, scattered, grayish scabs among the hair, of a very irre- 
gular form ; these scabs, compared by Alibert to fragments of 
mortar coarsely broken, resemble the detached portions that 
are sometimes seen in the thick incrustations of P. scutulata, 



and still oftener in P. larvalis, of which this eruption appears 
to be but a variety. They succeed to small pustules, which 
are in most cases irregularly disseminated over the scalp. 

It particularly occurs in children and young persons, but 
may also be seen in adults. It usually occupies the back part 
of the head, but may cover the whole scalp. 

Symptoms. — P. granulata first manifests itself by pus- 
tules of a yellowish-white colour, accompanied with some in- 
flammation, and much itching ; these pustules are traversed 
through their centre by a hair, and open in from two to four 
days, when an abundant discharge takes place. Brown, rough 
scabs soon form, which often agglutinate several hairs toge- 
ther. These crusts, in drying, acquire, after a certain time, 
the characters that constitute this variety. They become hard, 
rugged, and unequal, and of a brown, or dark gray colour. 
Small, unequal, dry, friable, irregular granulations become 
detached, and remain disseminated through the hair, which is 
stiff and bristling. 

The hair is never destroyed, but when the disease is exten- 
sive, it is formed into bundles from the agglutination of the 
scabs. The head exhales a disagreeable, sickening odour, 
which is sometimes so great in persons of filthy habits, that 
they infect all around them; in this case, lice are found in 
great quantities, both among hair, and under the scabs. This 
smell does not exist in patients who are cleanly; even the 
scabs do not, in a majority of instances, present their distinc- 
tive characters, but perfectly resemble those of Impetigo. 

The duration of this eruption is very variable; it seldom, 
however, lasts more than a few months. When left to itself, 
it may continue longer, but usually, when recourse has been 
had to a proper treatment, or even to cleanliness, it ceases in 
a few weeks. 

Causes. — This eruption is not contagious. Misery, un- 
cleanliness, privations, and unhealthy residences, are all causes 
that influence its development. It is the rarest of all the va- 
rieties of Porrigo, which may be explained from the want of 

29 



222 PUSTULAR DISEASES. 

stability in its characters, which depend on a peculiar state of 
an impetiginous affection. 

Diagnosis. — The diagnosis of this affection does not pre- 
sent any difficulty when it presents rugose, brown, or dark- 
gray scabs, resembling small bits of dirty plaster. Neverthe- 
less, there are certain cases where P. scutulata offers a mul- 
titude of analogous granulations, and indeed, many of the de- 
scriptions which have been given of P. granulata, may be 
referred to this eruption. But P. granulata never has the 
large, thick, and continuous incrustations that are to be met 
with in the other variety. Besides, when these scabs are de- 
tached, the circular form of the patches, and the nature of the 
pustules in the latter, will always suffice to distinguish it. As 
to P. favosa, independently of other characters, the colour of 
its scabs, and their cup-like depressions, will prevent any error. 

It is more difficult to distinguish it at its commencement, 
from P. larvalis or impetigo. In fact, there are the same 
pustules, the same scabs, &c. As to the peculiar appearance 
of those of P. granulata, when in a dry state, it may be re- 
garded as accidental. 

Prognosis. — This disease is seldom dangerous; sometimes 
it is obstinate, though much less so than the other varieties. 

Treatment. — To detach the scabs, cut the hair, and ex- 
pose the diseased surfaces, are the first indications to be ful- 
filled; this should never be forgotten, whatever may be the plan 
of treatment. Lotions and emollient applications are the only 
means that are suited to the commencing stage; at the same 
time the patient should take diluent drinks, rendered laxative 
by the addition of half an ounce of sulphate of potash or mag- 
nesia to the pint, or from two drachms to half an ounce of sul- 
phate of soda, &c. It is often necessary to continue the emol- 
lient applications for a long time, but at a later stage, when 
the inflammation of the scalp is slight, alkaline preparations 
should be used, as great benefit is often derived from them. 

Lotions, sulphurous douches, &c. also hold a high place in 
the treatment, which however is perfectly analogous at this 
period, to that of P. larvalis. 



( 223 ) 

ORDER V. 

PAPULAR DISEASES. 
PAPULJE. 

THE diseases arranged in this order, are characterized by 
small, solid, resisting elevations, which have received the 
name of pimples. Sometimes they are only constituted of a 
morbid enlargement of the papillae, and sometimes they are 
true elevations of the skin. Somewhat prominent, they never 
contain serum or pus; they are always attended with a greater 
or less degree of itching; which is sometimes intolerable. 
These affections are generally chronic, though they sometimes 
follow an acute course. Their duration varies from one or 
two weeks to several months or even years; the Prurigo, for 
example, may remain for an indefinite time. 

Seat. — There is no part of the skin, which is not liable to 
be attacked with papulae. The eruption, sometimes confined 
to a single region, may at others become general; but in most 
cases it occupies several parts, sometimes widely separated 
from each other at the same moment. On the limbs, the erup- 
tion usually appears on the external surface; on the body, it is 
principally to be seen on the posterior part. Finally, it gene- 
rally manifests itself on surfaces of extension. 

Symptoms. — The papulae are ordinarily developed in a 
slow manner, and preceded by a greater or less degree of itch- 
ing. They appear in the form of small, slightly prominent 
points, which are usually of the colour of the skin; sometimes 
however, they are red, and in some cases of Lichen, (stro- 
phulus,) on the contrary they are white. They gradually be- 
come more visible, and can be felt with the finger, which on 
being passed over the eruption, receives a sensation as from 
small, prominent, hard bodies. They are in most cases regu- 



224 PAPULAR DISEASES. 

larly rounded, and distinct, small in Lichen, and large in Pru- 
rigo. These eruptions are seldom accompanied with general 
symptoms. 

The papular affections terminate by resolution, or by a 
slight desquamation, which is the most usual, and sometimes 
by slight ulcerations which take place on the summit of each 
pimple, and change the appearance and condition of the dis- 
ease, (Lichen agrius. J An almost inevitable consequence of 
the papular eruptions, is a yellowish fawn-coloured appear- 
ance on those places that have for a long time been the seat of 
the disease. This may last for years. 

Causes. — None of these diseases are contagious; they are 
generally developed without any appreciable cause. Some- 
times they evidently arise under the influence of dirt and mi- 
sery, this is the case with the generality of the Prurigos. 

Diagnosis. — The diagnosis of papular inflammations, is ge- 
nerally easy, sometimes difficulties may arise, especially in 
distinguishing them from Scabies and certain cases of Eczema, 
but in the majority of instances, not to say all, a little attention 
will always detect the primitive constituent lesion, even when 
the disease has been disfigured to a certain degree, by small 
scabs which have succeeded to the ulcerations of which we 
have above spoken. 

Prognosis. — The prognosis is seldom unfavourable, but 
may sometimes become so, from the duration of the disease, 
which may attack all the dermoid tissue, and particularly 
from the pruritus of certain local species, which may become 
insupportable, and occasion dangerous symptoms, as in Pru- 
rigo of the penis, &c. 

Treatment. — Sometimes the papular affections yield to the 
most simple remedies; often, on the contrary, they are obsti- 
nate and untractable, and even in certain cases require the use 
of very energetic measures. The papulae constitute two ge- 
nera, Lichen and Prurigo. 



LICHEN. 225 



Lichen. 



The word Lichen from the Greek Af *#jjv, admitted by the 
^atin authors as synonymous to Impetigo, has been applied 
)y the English pathologists to papular affections. 

Lichen is characterized by full, solid, elevations, which are 
usually very small, sometimes of a light red colour, but gene- 
rally of the colour of the skin, almost always aggregated, and 
iccompanied with pruritus. It may be acute, but in most cases 
t is chronic. 

It may appear on all parts of the body, sometimes general, 
3ut ordinarily local, in which case the hands, the forearms, the 
neck and the face, are its most frequent seats. It may present 
two very different states, Lichen simplex and agrius. 

1 . Lichen simplex. — This appears in the form of very small 
pimples, rarely larger than the size of a grain of millet, ag- 
gregated in greater or less numbers, and presenting differences 
according as it is acute or chronic. In this eruption the pim- 
ples are red and inflamed, it is accompanied with heat and un- 
comfortable itching. At the end of three or four days the 
redness diminishes, a slight furfuraceous desquamation is es- 
tablished, and the disease terminates before the second week, 
without there should be successive eruptions. 

When it assumes a chronic state, which often is the case, 
the pimples are little if at all inflamed, and are generally of the 
same colour of the skin. Preceded by a slight itching, they 
appear in the form of small prominences perceptible to the 
hand, which on being passed over the eruption, receives the 
sensation of small hard bodies, with which the skin seems 
studded. In these cases, it is far from terminating at the end 
of seven or eight days; the papulae remain stationary during 
an indefinite time; fresh ones are developed, and the disease 
may last several weeks, and sometimes even months. Lichen 
simplex when chronic, is always accompanied with a greater 
or less thickening of the skin, and often gives rise to an ex- 
tensive exfoliation. 



226 PAPULAR DISEASES. 

Lichen simplex, when acute, is most generally fixed in the 
face, or on the body; in a chronic state, it is almost always 
met with on the limbs, as especially on the hands, of which it 
occupies the dorsal surface in most cases. 

Symptoms. — Developed without other symptoms than a lit- 
tle smarting, and sometimes a great degree of itching, the Lichen 
simplex is rarely attended with general symptoms, it is only 
preceded by a little uneasiness, and a slight fever in extensive 
and general cases where it is in an acute form. Sometimes 
the pimples appear on those parts of the body which are 
furnished with hair, ( L. pilaris,) in such instances it lasts 
for a long time. At other times, and particularly in indivi- 
duals enfeebled by misery and privation, the eruption assumes 
a livid hue, (L. lividus,) the pimples are soft, flat, and seat- 
ed on the inferior extremities, and are often mixed with pur- 
ple and hemorrhagic spots. This variety is very rare. 

The papulae of Lichen, although generally aggregated in ir- 
regular groups, may, in some instances, unite and form regu- 
lar figures, (L. circumscriptus, ) as circles, whose edges are 
well marked, and which are continually increased and aug- 
mented by new eruptions, at the same time that the centre 
heals with a slight exfoliation ; these circles are rarely isolat- 
ed, but appear in considerable numbers, and end in becoming 
confluent from their increase in size. 

There is another very rare form which is not noticed by 
writers, notwithstanding its remarkable appearance. M. Biett, 
who has observed and described it several times, has bestow- 
ed on it the name of Lichen gyratus. In fact, we have seen 
in a recent example at the Hospital of St. Louis, the papulae 
forming a kind of band, which, commencing at the anterior 
part of the breast, reached the internal portion of the arm, 
along which it extended in gyrations to the extremity of the 
little finger, exactly following the course of the cubital nerve. 

Independently of these anomalies in situation, aspect, and 
form, which are only modifications of Lichen simplex, it pre- 
sents two really important varieties, Lichen urticatus and 
strophulus. 



LICHEN. 227 

L. urticatus. — This is an eruption of a considerable num- 
ber of papulae, which are larger than the usual size in this 
species; they are inflamed, prominent, large, confluent, and 
resembling the stings from a nettle; they appear suddenly, 
and occasion a burning and uncomfortable itching; they are 
generally fixed on the neck and face, and particularly attack 
young persons and women in the spring and summer; they 
also appear in individuals whose skin is thin and delicate, and 
may occur in infants. The eruption is transient and irregular, 
usually disappearing spontaneously to reiterate its attack in a 
short time; it terminates by a furfuraceous desquamation. 

L. strophulus. — This affection is a variety which is pecu- 
liar to infants at the breast; it always exists in an acute state, 
and consists in an eruption, (which is almost always general, ) 
of papulae, either redder or whiter than the skin, accompanied 
with violent itching, which is augmented by the heat of the 
bed, and is subject to well-marked exacerbations. It presents 
a multitude of varieties in colour, form, and dimensions, which 
are usually to be seen in different eruptions, but may some- 
times occur at the same time. 

Sometimes the papulae are red, much inflamed, and promi- 
nent, and are scattered here and there, intermixed with small 
erythematous patches, (S. intertinctus,J or else they are 
smaller, more contiguous, and much more numerous, and con- 
stitute an eruption of some severity, (S. confertus,) or even 
they may appear in small groups, regularly rounded and at 
considerable distances from each other, (S. volaticus. J 

Sometimes the papulae are white, and in this case, they may 
be small, of little extent, and encircled with a slight inflam- 
matory areola, (S. albidus,) or large, prominent, and with- 
out inflammation at their base, (S. candidus. ) 

This disease is generally developed under the influence of 
some unknown cause, and often accompanies the first denti- 
tion, sometimes appearing to be connected with inflammation 
of the internal organs. Its duration varies from one to three 
or four weeks. It is usually an ephemeral disease, and always 
unattended with danger; it seldom requires any other treat- 



228 PAPULAR DISEASES. 

ment than a few tepid baths for the child, and cooling drinks 
for the nurse; but should always attract the attention to the 
causes which may have produced it, and which sometimes re- 
quire immediate treatment.* 

2. Lichen agrius. — This may occur spontaneously, or suc- 
ceed to L. simplex. 

The first manifests itself by a multitude of very red, small 
pimples, which are much inflamed, and developed on an 
erythematous surface; they are small, in great numbers, pro- 
minent, and acuminated, the surface they occupy is generally 
of small extent, and surrounded by a strongly marked in- 
flammatory redness, accompanied with heat and painful swell- 
ing; the solid elevations increase in size, and the inflammation, 
far from diminishing on the fourth or fifth day, appears to 
augment; the summit of the pimples becomes the seat of small 
ulcerations, and discharge a sero-purulent fluid, which con- 
cretes in the form of real prominent, small, yellow scabs, 
somewhat rough but soft, and slightly adherent; these crusts 
fall off, and are replaced by thin scales. Sometimes the red- 
ness then diminishes, and a slight exfoliation occurs, the dis- 
ease terminating in twelve or fifteen days; but in most cases, 
an abundant secretion continues, the scales fall off, and are 
again renewed for an indefinite time. The Dartre squameuse 
of Alibert, which, as we have seen, corresponds to Eczema, is 
also analogous to this state of Lichen. 

This variety is accompanied with itching, which is some- 
times so violent that the patient cannotfind substances sufficient- 
ly hard to scratch himself with ; sometimes it is aggravated by 
painful exacerbations and fresh eruptions. It may last in this 
state for several weeks, sometimes, however, it passes at once 
into a chronic condition; the quantity of sero-purulent fluid 
secreted, becomes less and less abundant, the scabs become 

* The varieties of L. strophulus are all known under the common name of 
tooth-rashes. The confertus being the tooth-rash, the intertinctus the red-j 
gum, and the albidus the white-gum. As stated in the text, they required 
little medical treatment more than to keep the bowels in a soluble condition, 
and strict attention to cleanliness. — Tbaxs. 



LICHEN. 229 

drier, and are replaced by a farinaceous desquamation; this 
state is accompanied with a thickening of the skin, which is 
sometimes very considerable, and may last for months. 

L. simplex may pass into L. agrius ; in this case, the pa- 
tient experiences, instead of the constant itching, an unaccus- 
tomed smarting and heat. The pimples appear to become 
confluent, and are surrounded by a small, reddish areola; they 
acquire a great redness, and the eruption then pursues the same 
course as spontaneous L. agrius; in these cases, all the erup- 
tion may not participate in the inflammation, which is besides 
always less violent, of less duration, and instead of being un- 
favourable, is often attended with salutary effects. 

L. agrius may be developed on the face, but it is rarely 
general; it is most usually observed, not, as has been said by 
a modern author, on individuals enfeebled by age, &c. but in 
young persons and in sanguine and vigorous adults. 

Causes. — Lichen affects all ages, from the infant at the 
breast to old persons, and is met with in both sexes; it particu- 
larly arises in the spring and summer; elevated temperatures 
influence its development in a remarkable manner; it is often 
produced on the face by the heat of the sun ; it is very com- 
mon in tropical regions, and a species, though erroneously, 
has been constituted from these cases, ( L. Tropicus;) it is 
sometimes the result of prolonged watchings, of violent men- 
tal affections, excesses, particularly in spirituous liquors. 
Some causes appear to produce certain local varieties; it is ob- 
served on the hands, for instance, in persons who work among 
pulverulent substances, as sugar, &c. it is also seen on the arms 
of cooks, and blacksmiths from being exposed to an ardent fire; 
finally, it sometimes appears to be the result of internal inflam- 
mations, especially in children. 

Diagnosis. — The diagnosis of this disease is often very 
difficult: the L. simplex may above all be confounded with 
Eczema, Scabies, and Prurigo; but the essential character of 
the Lichen is, full solid pimples, usually appearing on the outer 
side of the limbs, and accompanied with itching; whilst Ecze- 
?na is characterized by transparent vesicles, mostly situated 

30 



230 PAPULAR DISEASES. 

on the abdomen and internal surface of the arms, &c. and only 
attended with a little smarting. 

Scabies, independently of its constituents being so different, 
(it is vesicular,) attacks the surfaces of flexion, the bends of 
the articulations, and the spaces between the fingers. The 
vesicles are distinct, the papulae in Lichen are grouped; and 
finally, the former is contagious. 

The papulae of Prurigo have their seat as in Lichen on the 
external faces or surfaces of extension of the limbs; but they 
are larger and flat; their summit is almost always lacerated, and 
covered with a small blackish scab, formed of a small drop of 
dried blood. The pruritus of L. simplex is usually very slight, 
whilst it is violent and burning in Prurigo. 

Lichen circumscripta may be confounded with Herpes 
circinnatus, but the edges of the latter rest on a more inflam- 
ed surface than in the former. They are better marked in 
Lichen, and generally retain the natural colour of the skin. 
The patches are papular, both at their centre and circumference, 
and it is only at a very advanced stage of the eruption that 
the first becomes healthy. On the contrary the centre is gene- 
rally untouched in Herpes, added to which it is never vesicu- 
lar. Finally, with a little attention, the essential character 
will be found in most cases^ of Herpes, either in the vesicles 
themselves, or in their remains, which present a multitude of 
small red, rounded points, surrounded by a small whitish 
band, which is formed by the portion of epidermis that con- 
stituted the base of each vesicle. The surface of Lichen is rough 
to the touch. 

Lichen urticatus, from the size of its papulae, may some- 
times be mistaken for Erythema papulatum or syphilitic 
lichen; the patches of Erythema are much larger, not as 
red, and less prominent, they are never accompanied with the 
violent itching that constantly exists in this variety of Lichen; 
finally the erythematous affection does not like Lichen, disap- 
pear and return successively. In the syphilitic lichen, the pa- 
pulae present a coppery tint; they are never inflamed like those 
of L. urticatus, and are not attended by a continual itching. 



LICHEN. 231 

The syphilitic papulae follow a much slower course, and are 
never transient. Finally, they are seldom the only characters 
by which the venereal disease shows itself, as it is usually attend- 
ed with concomitant affections, and particularly Iritis, of which 
we have seen several examples in the Hospital of St. Louis. 

Lichen agrius in its different stages, may resemble acute 
Eczema, Impetigo, chronic Eczema, or Psoriasis. The 
confluent and ulcerated papulae may be taken for acute 
Eczema; but the diseased surface itself, or the environs, 
always present some of its constituent principles, (papulse,) 
in a less advanced stage, which will soon dissipate the error. 

It ought not to be confounded with Impetigo, for in Lichen, 
the small scabs are thin, soft, and but little adherent; besides they 
are consequent on ulcerated papulae and not on pustules, a lesion 
that is never to be observed in these cases, whilst a multitude 
of inflamed papulae are always to be seen around the eruption. 

It is much more difficult to distinguish it from chronic 
Eczema; the pruritus, the thickening of the skin and the ex- 
istence of some papulae, are the only characters by which we 
can ascertain the presence of the Lichen. 

In cases of Psoriasis, the scales are always larger than the 
small farinaceous exfoliations of L. agrius in a chronic state; 
they leave on their disengagement a red slightly swelled sur- 
face, which is never observed in Lichen, without it be a Pso- 
riasis invetera, but in such case the characters are so well 
(narked that no mistake can ensue. 

Prognosis. — Lichen is never a dangerous disease, but its 
obstinacy, its pruritus, and frequent returns, renders it in 
nany cases a very unpleasant malady. L. simplex is usually 
i very slight affection, and the duration of which is rarely ex- 
tended between two or three weeks. L. agrius is generally 
more dangerous, and above all more refractory. 

In chronic Lichen the skin is dry, rough, hard, and furrowed 
3y deep fissures, especially at the articulations. At the spots 
vhich are the seat of the eruption, the exhalent system is in a 
state of complete inertia, and M. Biett has several times ob- 
served that, under the influence of a vapour bath, these spots 

-Aill J i/l- •_ J 



232 PAPULAR DISEASES. 

Lichen may be complicated with vesicles, with pustules of 
Impetigo, or even of Ecthyma. As it always terminates 
by resolution or desquamation, it may remain stationary for a t 
long time, but it is never converted into Psoriasis, and still 
less into Impetigo, as has been said by Willan, and by the au- 
thor of a recent work. 

Treatment. — Acute L. simplex does not require any other 
treatment than a few diluent drinks and tepid baths, or even 
those of river water, which, in the generality of cases, are all 
that should be advised in cases of L. urticatus. 

When it is chronic, recourse must be had to lemonades, 
mild laxatives, alkaline and sulphurous baths, to local emol- 
lient bathing, at first, (scalded bran, &c.) and afterwards ren- 
dered alkaline by the addition of subcarbonate of potash, in 
the proportion of half an ounce or an ounce to four or five 
pounds of water: there is rarely occasion to employ more ener- 
getic means, which, besides, would be the same as we shall 
indicate for L. agrius. It is sometimes, however, advanta- 
geous to anoint the surface of the eruption with a salve com- 
posed of calomel and camphor, (pulv. calom. 3ss. gum. camph. 
gr. xij. axunge, §i.) or of protoioduret of mercury, gr. xij. to 
9i. to axunge, ^i. 

In L. agrius, at its commencement, if the patient is young, 
vigorous, and sanguine, one or two general bleedings should 
be practised. Topical bleedings are also often useful, but not 
on the eruption; diluent drinks, emollient cataplasms, and sim- 
ple tepid baths should also be ordered; the patient is to be put 
on a severe regimen, or even very low diet, particularly if 
symptoms of irritation of the gastric organs exist; if, on the 
contrary, these viscera present no signs of alteration, the mi- 
neral acids, as the sulphuric and nitric, may be employed with 
advantage in the dose of 3i. to a pint of barley water. 

At a more advanced stage, mild purgatives may be admi 
nistered; calomel, in the dose of four grains daily, or casto 
oil in small doses, (one ounce,) two or three times a week. 
Alkaline and sulphurous baths should never be given at th 
beginning, they aggravate the disease; at a later period, o 
the contrary, when the inflammation is diminishing, they an 



I 



PRURIGO. 233 

very useful. Finally, if the disease continues, recourse must 
be had to the arsenical preparations, as Fowler's and Pear- 
son's solution, the first in the dose of five drops at the begin- 
ning, and successively augmented by five drops every eight 
days, up to twenty -five or thirty, intermitting its use from 
time to time, or even discontinuing it, if any symptoms of 
gastric irritation should supervene. The other is given in the 
dose of half a drachm to a drachm, for a month or six weeks, 
with the same precautions. The Asiatic pills have often been 
employed, both in these cases, or even those of chronic L. 
simplex, with success, the patient is to take one, daily, for 
a month or more. The local frictions, spoken of above, also 
are useful in chronic L. agrius, but it is advantageous to make 
them stronger, as, for example, the deutoioduret of mercury 
with axunge, in the proportion of fifteen or twenty grains to 
the ounce. 

Prurigo. 

This denomination, introduced by Willan, was adopted by 
Alibert, but he has latterly used the term of Psoride papuleuse. 

Prurigo is characterized by papulae, which are larger than 
those of Lichen, without any change in the colour of the skin, 
generally appearing on the surfaces of extension, and accom- 
panied by a pruritus which is sometimes intolerable. It is 
always chronic, and its duration varies from a month to seve- 
ral years. 

Seat. — It usually occupies several surfaces, but is sometimes 
more violent, and may extend over the whole body, limbs, 
and even face, but the neck and shoulders are its usual seats. 
When it appears on the limbs and face, it is always of long 
standing and severe; it is also entirely local, and confined to a 
circumscribed spot. 

There have been three varieties established: P. mitis, P. 
formicans, and P. senilis; the two first only differ in in- 
tensity, and hence no distinction should be made; the latter, 
however, presents a peculiar modification. 



234 PAPULAR DISEASES. 

Symptoms. —Prurigo manifests itself by papulae, sometimes 
small, little prominent, appreciable to the touch, and accom- 
panied by an uncomfortable itching, (P. mitis;) sometimes 
larger, more prominent, and flattened, attended by an intole- 
rable pruritus, which augments in the evening from the warmth 
of the bed, and has been compared to the bites of insects or 
ants, or to pricking with hot needles, (P. formicans. J These 
papulae are distinct and isolated, generally of the same colour 
as the skin, when they have not been lacerated by the action 
of scratching, and occupy, in most cases, the back part of the 
body, and internal surface of the limbs. They may be few in 
number, and the itching slight. 

At other times, on the contrary, and especially in young per- 
sons, they are very numerous, the pruritus is excessive, the nails 
irritate them continually, and they become torn at their sum- 
mits, from whence flows a small drop of blood, which coagulates 
and forms a small blackish scab, constituting an accidental but 
specific character. In some cases the scab falls off and exposes 
a prominent point, which is, however, very small, sometimes 
even the papula has entirely disappeared. Those which have 
not been lacerated, either disappear by resolution or by a 
slight desquamation, and the disease terminates in two or 
three weeks; at other times, and more generally, the papulae 
remain for a longer time, new ones are formed, and the disease 
lasts from one to three months. Under some circumstances, 
which are frequently met with, especially in elderly persons 
and in debilitated children, the disease lasts for two or three 
years, sometimes indeed for an indefinite period; it becomes 
general, the papulae are hard, very large, and prominent; the 
eruption is accompanied by a thickening of the skin, which is 
sometimes very considerable, and presents violent exacerbations 
from time to time, during which the papulae become confluent, 
the skin swells and inflames for a considerable extent: it may 
be covered with vesicles, pustules, and boils, and sometimes 
forms abscesses; there are often general symptoms, as fever, 
excitement, and wakefulness, and sometimes gastrointesti- 
nal inflammation, &c. Finally, in these obstinate and re- 



PRURIGO. 235 

fractory cases, the patient is tormented with a terrible pruritus, 
and it is to these particularly that the exaggerated descriptions 
of the torments experienced by persons labouring under this 
disease, are most applicable. 

When the papulae in Prurigo are very numerous, and when 
they are developed several times successively, on the same 
surfaces, they appear to affect the dermoid system more pro- 
foundly, as on the places they have occupied are seen small 
slight cicatrices, but at the same time visible to the naked eye. 

Causes. — Prurigo attacks all ages, and both sexes; but it is 
generally met with in old persons and children; it appears at 
all seasons, but more especially in the spring and autumn; it 
may be found in all ranks of life; nevertheless low and hu- 
mid habitations, want of linen, misery, uncleanliness, priva- 
tions, salt food, fish, and shell-fish, appear to be so many 
causes of its development; it sometimes supervenes on violent 
mental affections. Its special causes are very obscure. 

Diagnosis. — The diseases with which Prurigo may be 
confounded are Lichen, and some of the vesicular affections. 

The papulae of Prurigo are larger and more diffused than 
those of Lichen; the latter is never surmounted by the small 
blackish scabs which so often occur in the former; in Lichen 
the pruritus is much less. 

By making a close examination, this eruption can never be 
mistaken for the vesicular affections; the elementary lesions 
are wholly different, besides it has not the same seat, the 
same kind of eruption. 

Nevertheless, Scabies, in some instances, might perhaps to 
a certain point, be taken for Prurigo; but the papulae of this 
last are flat, and of the same colour as the skin; the vesicles 
in Scabies are acuminated and rosaceous. Prurigo always 
presents a multitude of papulae surmounted with a small 
blackish crust, whilst the small scale that sometimes covers 
the lacerated vesicles of Scabies, is yellowish and thin; Pru- 
rigo has its seat on the back, shoulders, and the limbs on their 
surface of extension; Scabies occupies just the opposite points; 
it is met with on the abdomen, the internal surface of the 



236 PAPULAE DISEASE?. 

arms, and the thighs on their surface of flexion; in this case, the 
itching is much less acute. Prurigo is never contagious. 

Prurigo may exist with Lichen, with Scabies, and with 
Eczema ; and may be complicated with pustules of Impe- 
tigo and Ecthyma. 

It terminates by resolution, and by a furfuraceous desqua- 
mation; this last is very common in chronic Prurigo. 

Prognosis. — Prurigo being often refractory, constitutes a 
disease, which though not serious of itself, is at least trouble- 
some from its obstinacy, and the pruritus that accompanies 
it ; it is subject to frequent relapses. It is sometimes incura- 
ble in debilitated persons, who are plunged in misery, and 
who have been attacked with it several times. 

Treatment. — The treatment of Prurigo, (miiis and/or- 
micans,) consists in the simple cases, of alkaline drinks, (bar- 
ley water with two drachms of subcarbonate of potash to the 
pint, ) and some baths. Willan has advised sulphur united to the 
alkalies, (the subcarbonates of soda and potash;) M. Biett has 
often obtained good effects from them in the proportion of one 
part of the salts to three of sulphur. In more serious cases, 
recourse is sometimes had and with advantage, to acidulated 
drinks, made by adding one drachm of nitric or sulphuric 
acid to the pint. When the constitution is injured, the pa- 
tient should be kept on a generous diet; when the digestive 
organs are out of order, a milk diet is proper. 

If the skin is delicate and irritable, all stimulating applica- 
tions are to be avoided; if on the contrary, it is rough and 
dry, saline and alkaline lotions, alkaline baths alternated with 
those of vapour and of sea-water, must be resorted to. In 
general, ointments are of little use, but in some cases, sul- 
phuro-alkaline lotions, (sulphuret of potash 3ii- subcarbonate 
of potash 3i- water ffei. ) are advantageous, particularly on 
the decline of the disease, when the pruritus has diminished. 

Lotions of the acrid plants have been recommended, as 
white hellebore, stavesacre, &c. They are generally useless, 
and always inflame the skin. 

Sometimes opiates are obliged to be used internally, to 



PRURIGO. 237 

calm the irritation and general excitement which is induced 
by the exacerbations of the pruritus in some cases. Finally, in 
young persons, and especially in children, it is sometimes useful 
to make use of sulphur combined with magnesia, (sulph. sub. 
magnes. ust. aa 5ss. divided into four doses,) the patient is 
to take a powder every day, to this is to be added diluent 
drinks, simple baths, at first emollient, and afterwards render- 
ed alkaline by the addition of one, two, three, or four ounces 
of subcarbonate of potash to a bath, according to the age of 
the patient. 

Blood-letting is usually of little service, and should be 
only used in young and vigorous individuals. All these 
means should also be seconded by an appropriate regimen. 

Prurigo senilis, (ptdiculaire.) — This differs from the pre- 
ceding but little, as to the papulae; they are perhaps, less pro- 
minent, rather flatter, and less numerous. The dryness of 
the skin, which in P. formicans is only accidental, is here a 
specific character; but the great difference is, that all the 
body is covered with insects ; the ancients attributed this dis- 
ease to the anger of the Gods. 

It generally attacks old persons. Nevertheless, M. Biett 
has seen a woman who was still young, affected with it after 
delivery. It is, however, almost always met with in the de- 
cline of life, in individuals enfeebled by misery, but rarely in 
robust and healthy elderly persons. The skin is brown, its 
functions are almost destroyed ; the body is covered with in- 
sects, which increase and multiply with astonishing rapidity. 
These insects usually belong to the genus Pediculus. Willan 
has also observed the genus Pulex. The presence of these 
insects is a character sufficiently remarkable and characteris- 
tic to prevent this disease from being confounded with any 
other affection. It is a serious and often incurable disorder, 
it may, however, be moderated. 

The means we have advised above, are applicable to the 
treatment of this disease; but there are some remedies that are 
peculiarly suited to it, as the sulphurous baths; but one of the 
most efficacious modes is the use of fumigations with cinna- 

31 



238 PAPULAR DISEASES. 

bar, which almost always will destroy the insects ; it acts more 
promptly, and is more easily used than mercurial frictions, 
which have been advised in these cases, but they are often at- 
tended with many inconveniences. Finally, it is generally ad- 
vantageous to give the patient some ferruginous preparations, 
(chalybeate wine, &c. ) bitters, and generous diet. Cleanliness 
must be attended to as much as possible. 

Willan has admitted several local species, in which it is ex- 
tremely rare to discover papulae, but which appear to apper- 
tain to Prurigo, by the itching that accompanies them. The 
pruritus may be confined to a small spot, and constitute seve- 
ral varieties, the most interesting of which are Prurigo of the 
genitals, and that of the anus. 

Prurigo of the genitals. — This variety occurs in the scro- 
tum in men, and the pudendum in women; it may, in both, 
extend to the adjoining parts; it often reaches the interior of 
the vagina, and may exist with P. podicis. In men, there is 
a secretion of sebaceous matter; in most cases, there are no pa- 
pulae to be met with ; in some rare instances, however, slight 
papular elevations maybe observed: the skin of the scrotum be- 
comes brown, and sometimes thickens; there is constantly an 
intolerable pruritus, which the patients can scarcely bear; they 
scratch and tear themselves terribly. It comes on in exacer- 
bations. In women, the symptoms are even more severe; the 
disease gains the vagina; it often causes onanism, at first, 
from merely scratching to relieve the itching, afterwards to cre- 
ate a voluptuous pleasure. In many cases, nymphomania may 
take place. M. Biett has seen it in a woman of sixty years 
of age ; he examined the genital parts with a glass, but could 
discover nothing. Nevertheless, this woman had frequent| 
pollutions; the disease at first began with itching, this augment- 
ed and assumed the character of nymphomania; the patient 
had fainting fits at the sight of young men. This terrible pru- 
ritus, the absence of all redness, of all signs of vesicles, distin- 
guishes this disease from certain cases of Eczema, which some- 
times occur in this spot, and are accompanied with itching. 

This eruption is often developed without any appreciabl* 



PRURIGO. 239 

cause. Chafing of woollen garments, violent exercise in hot 
weather, and the general causes of Prurigo may influence its 
appearance. It often accompanies a chronic discharge in wo- 
men; it also frequently occurs at their critical period, and 
finally it coexists with P. podicis. This only differs from 
the preceding by its seat; it particularly attacks sedentary per- 
sons; and often attends haemorrhoids or ascarides in the rectum, 
or even a chronic inflammation of the intestine. It may also 
be produced by the same Causes as the other species of 
Prurigo. 

The patients experience a most troublesome itching around 
the sphincter, which sometimes extends into the intestine; this 
pruritus, which augments in the evening, and from any excess, 
sometimes plunges them in a state of excitement and agitation 
that is horrible. 

These local species are sometimes very serious; they are al- 
ways obstinate, and there is often great difficulty in allaying 
the itching. In some cases, however, they yield to applica- 
tions of leeches around the affected parts, to lotions, at first 
emollient, then cold, and sometimes alkaline or opiated, to 
local cold bathing, and alkaline or sulphurous baths. The 
sulphurous, and sometimes the cinnabar fumigations, are par- 
ticularly useful under these circumstances. 

This latter means has above all, been employed with de- 
cided advantage by M. Biett, in several cases, but as it is 
obliged to be used for some time, it results that general fumi- 
gations, by means of the apparatus of Darcet, will eventually 
greatly weaken the patient, which determined M. Biett to in- 
vent an apparatus, by the aid of which he could apply the fu- 
migation to the affected part only. This is daily used in the 
Hospital of St. Louis, and the bathing establishment at Eng- 
hien. Nevertheless, in spite of the employment of these va- 
rious plans, the Prurigo of the genital parts, particularly in 
women, may last six months and upwards. We have seen it 
remain for years: it has perfect remissions, and prompt and 
frequent returns. 

It is wrong, it may be perhaps said, that we should describe 



240 PAPULAR DISEASES. 

diseases, which, in most cases, do not present the constituent 
character; but besides, that this is sometimes observed, though 
rarely, it is true, the pruritus which allies them to Prurigo^ 
and their importance have determined us not to reject them 
entirely, added to which, they have been described by Willan.* 

* Dr. Dewees, in his work on " the diseases of females," has discussed 
this complaint at some length; as it is impossible to present his views in a 
short note, we refer our readers to that excellent and practical treatise. 

Dr. Ruan, of this city, has also published a short notice of this disease in 
Vol. VI. p. 234, of the North American Medical and Surgical Journal, in 
which he tried various remedies in different cases, and was successful in one 
case with the balsam copaiba given internally. Here the pruritus appeared to 
have been excited from the occurrence of strangury. This remedy was also 
successful in another instance, but failed in some others, which were cured 
with a solution of borax, and powdered lapis calaminaris,— Trass. 



( 241 ) 

ORDER VI 

SCALY DISEASES. 
SqUAMJE. 

IN this order are arranged those chronic inflammations of 
the skin, which are characterized by the formation on the dis- 
eased surface, of a lamellar, inorganic substance, of a gray- 
ish-white colour, dry and friable, of various thickness, and 
more or less adherent. These whitish lamellae have received 
the name of scales; they generally surmount elevations of the 
skin, which are more or less prominent, and leave this mem- 
brane, on their disengagement, in a red and inflamed state. 
Being a morbid secretion from the epidermis, they are very 
different from the scales that are observed in the vesicular af- 
fections, which are the result of a concreted fluid. 

The diseases described by Alibert under the common name 
of Dartre squammeuse, do not all belong to this order; it is 
only the Dartre squammeuse lichenoide, and the Dartres 
squammeuses orbiculaire and centrifuge, which are only va- 
rieties of the first, that correspond to the scaly diseases, pro- 
perly speaking. The Dartre squammeuse humide of this 
pathologist, belongs, as we have already said, sometimes to 
Eczema and sometimes to Lichen. On the other hand, it is 
here that two eruptions, which constitute a particular order of 
the same author, should be placed; the Dartre furfuracee 
volante and the Dartre furfuracee arrondie: the first has been 
described by Willan under the name of Pityriasis, the second 
is the Lepra of the English pathologists. 

All these affections follow a chronic march, they are gene- 
rally developed in a slow manner, but sometimes so rapidly 
that the eruption takes place in two or three days; they often 
last for several months or even years. 



242 SCALY DISEASES. 

Symptoms. — At the commencement, several points may- 
be observed on the surface of the skin, which are red, slight- 
ly tumefied, isolated, and distinct. Sometimes these small 
centres of inflammation are contiguous to each other, become 
joined and confluent, and at the same time are covered with 
scales, they appear in certain fixed forms, and thus constitute 
such or such a genus or species. These diseases take place 
without general symptoms, even the patient is unconscious of 
them, in most cases, until the eruption is developed, and the 
epidermis on the point of exfoliating. These affections occur 
more frequently on the legs than elsewhere, nevertheless they 
are also to be met with on the body and head; the patches of 
eruption are often widely separated and few in number, but 
they may also cover a whole limb, and form, as it were, a 
complete case to it. The nature of the scales differs according 
to the variety, but they appear in all cases to be a diseased se- 
cretion of the epidermis ; they are sometimes thin and light, 
and seem to be nothing more than portions of this membrane 
become dry and white, and are detached with great ease and 
in great quantities: sometimes they are more adherent, and are 
formed of altered and thickened cuticle. 

All the train of symptoms that are found in authors, as con- 
stantly accompanying the scaly affections, and with great se- 
verity, exist, on the contrary, but seldom, and when they are 
accidentally observed, they are far from being well marked. 
The patients may, it is true, feel some itching, but even this 
is not a constant symptom. Sometimes, the movements of 
the joints are impeded, if they should be surrounded by a 
great number of patches of eruption; and when the disease is 
of long standing, that part of the skin on which it is seated, 
and the functions of which have been for a long time in a dis- 
eased state, undergoes an alteration, and thickens. 

Causes. — None of these chronic inflammations of the skin 
are contagious; they may, however, be hereditary. One of 
them, (Ichthyosis,) is very often congenital. They attack 
individuals of all ranks, both sexes, and all ages, but more 
particularly adults. They appear at all seasons, but they some- 



LEPRA. 243 

times seem to have a kind of predilection for a certain season ; 
thus the disease developed in the autumn, may cease after 
some time, and again take place the succeeding autumn. 

Diagnosis. — These affections cannot be confounded with 
any of the diseases belonging to the other orders. The pre- 
sence of the scales is a sufficient character; it is true there are 
some acute eruptions, which also present this morbid change, 
but they are not, as in these cases, simple laminae of epider- 
mis in different degrees of alteration, but, being preceded by 
small serous or sero-purulent effusions, they are the result of 
the concretion of these fluids; they are not thin, dry, grayish, 
and friable, but are large, soft, yellow deposits, resting on 
soft and inflamed surfaces, and constantly surrounded by pri- 
mitive lesions, similar to those which produced them, as the 
vesicles of Eczema or the papulae of Lichen. Even deprived 
of their scales, and without an inflamed surface, these erup- 
tions may be distinguished by their form, by the surface they 
leave exposed, by the absence of the primary lesions, &c. The 
squamose diseases rarely occasion serious consequences; but 
they are often obstinate, and require energetic treatment. 

This order contains four genera: Lepra, (Dartre furfu- 
racee arrondie, Al. ) Psoriasis, (Dartre squammeuse liche- 
noide, A\.) Pityriasis, (Dartre furfuracee volante, Al.J 
and Ichthyosis, which, with Willan, we retain in this order, 
as it presents the same essential characters as the other genera, 
although it differs in its nature and in the deep alteration of 
the skin. 



Lepra. Lepra Vulgaris, Will. Dartre furfuracee ar- 
rondie, Al. 

For a long period of time, and especially from the revival 
of learning, when the Elephantiasis was regarded as syno- 
nymous to Lepra, by the followers of the Arabian school of 
medicine, this last denomination has been employed for a va- 
riety of different affections, including almost all the diseases 
of the skin; this necessarily caused the greatest confusion, 



244 SCALY DISEASES. 

till Willan, supporting his opinion upon what the Greeks had 
originally termed *tirf>» from Ae7r/$, Squama, a scaly dis- 
ease, manifesting itself in the form of circular patches, has re- 
stored it to its original signification. We understand, with him, 
by the word Lepra, a scaly eruption, characterized by round- 
ed patches, elevated at the edges, depressed in the centre, and 
sometimes becoming confluent, so as to form a continuous 
eruption over the body, or some of its parts. 

The varieties that have been admitted cannot be preserved. 
One, Lepra alphoides, only differs from the vulgaris by its 
less size, and rather whiter appearance of the patches; it is ob- 
served in children and debilitated persons: the other, Lepra 
nigricans, is a rare disease, which Willan, and after him, in 
all probability on his authority, Rayer, have erroneously ar- 
ranged with this disease; it is evidently a syphilide, and will 
be described in its proper place. 

Symptoms. — Lepra, although it may appear on all parts 
of the body, generally attacks the limbs, around the joints, 
and particularly the elbows and knees; at least it usually com- 
mences in these places, in the form of small red points, which 
are scarcely visible, and slightly elevated above the level of the 
skin. These smooth, shining elevations, become covered 
with an extremely thin scale, which is soon detached; little 
by little the patches increase, always preserving a circular 
form; the scales are renewed, become thicker, and overlay 
each other, particularly on the elevated edges; the centre re- 
mains healthy, except in some rare cases, where isolated 
patches are met with, whose character is disguised by the scales 
which occupy their whole extent. This orbicular appearance 
continues till they have attained a diameter of some inches, 
and even in some instances far greater, but in general they do 
not arrive at this size; the disease now becomes stationary, 
and circular patches are observable, whose size ordinarily 
varies from that of a shilling, to that of a dollar; the healthy 
centre is depressed, and the edges are elevated and covered 
with numerous, grayish, adherent scales. 

These circular spots are not always entire and distinct: even 



LEPRA. 245 

from their first development, the small elevations become 
united, so that their edges intersect each other, giving rise to 
irregular and confluent patches. This form is very common, and 
indeed almost universal, around the articulations. Whilst this 
individual development is thus advancing, the general erup- 
tion is also increasing; it progressively extends over the ab- 
domen, the shoulders, back, and breast, sometimes over the 
scalp and forehead, and in rare cases includes the face and 
hands. 

The scales fall off and are renewed continually, they leave 
on their disengagement, a red surface slightly inflamed; 
smooth if the eruption is recent, and furrowed and rough, if it 
is of long standing. Such are the characters with which this 
disease appears in the majority of cases; but it sometimes 
occurs with symptoms, which, if not widely different, are at 
least very remarkable. 

Thus on the one hand, departing in its development from its 
usual course, the eruption may manifest itself by small red 
points, disposed in a circular manner, and which become 
joined at their circumference; either from one, or several of 
the elevations acquiring a great size; and on the other part, the 
patches may never be covered with scales, or else having fallen 
off from some unknown cause, they have not been renewed; 
we have seen many patients at the Hospital of St. Louis, where 
the eruption presented the following characters: The body, 
and especially the back, was the seat of large, very red patches, 
sometimes more than afoot in diameter, they were constituted 
by a prominent circle, of only a few lines in breadth, and ac- 
companied on both its inner and outer edge, by a reddish band 
of about the same width; the centre presented a large surface, 
and was perfectly healthy. These prominent edges were not 
covered with scales; and sometimes two or three rings alone, 
and even in some instances but one, occupied the whole back. 
We have seen patients on whose body, the Lepra being of this 
immense extent, and unaccompanied by scales, impressed a 
most singular aspect. 

At the same time there are patches on the limbs, which fol- 

32 



246 SCALY DISEASES; 

low the usual course, and present the common characteristics 
of the eruption as above described. Lepra may remain sta- 
tionary for a great length of time, without producing any other 
symptoms, or without the internal functions being sensibly 
altered; except that at last a swelling of the joints may occur, 
that occasions some difficulty in their movements. As to ul- 
cerations taking place, and leaving scars; they never exist, or 
are the result of some rare accident, wholly independent of 
the eruption. 

If left to itself, Lepra may disappear and return again, or 
it may remain for a greater or less time, and only yield to the 
most energetic treatment. Whether it disappears under the 
influence of some unknown cause, or from medical treatment, 
the progress of the cure is very slow. At first the patches 
heal in the centre, the scales are formed more rarely, they are 
less numerous, and finally they cease to be evolved, the cure 
always taking place from the centre towards the circumference, 
the circles become disjoined in several places, the elevations 
disappear, and the patches vanish. In that variety where the 
Lepra appears in the form of immense circles of a red colour 
and without scales, before disappearing, the surfaces be- 
come much more inflamed, the edges soon fade, portions of 
the circle sink to the level of the skin, the colour becomes 
lighter, and at last a slight injected appearance, (which soon 
ceases,) is all that is apparent. 

Causes. — Lepra is not contagious, it appears at all seasons, 
but is most frequently met with in the autumn. It more com- 
monly attacks men than women; perhaps because they are more 
exposed to the different causes that may produce it. It is sel- 
dom observed in children. The causes that act in its produc- 
tion are but little known; nevertheless we have been able at 
the Hospital of St. Louis, to verify some, among the great num- 
ber that have been assigned. Thus it may appear from the 
effects of a cold and damp atmosphere; it frequently arises from 
the ingestion of salt meat or sea-fish. Certain professions pre- 
dispose to it, as for example, those in which persons are ex- 
posed to the action of pulverulent substances, or of the metals. 



LEPRA. 247 

One of the most common causes is to be traced to the mental 
affections ; hence it is not rare to see Lepra vulgaris super- 
vene on a fit of anger, or violent grief or fear. It may also be 
hereditary. 

Diagnosis.— -The diagnosis of Lepra is very easy in a 
majority of cases, and the slightest inspection will suffice to 
distinguish it from diseases of the other orders. We will 
however indicate the characters in which it differs from those 
with which it has sometimes been confounded. 

Porrigo scutulata at certain periods, either at its com- 
inencement, or when the scabs have fallen off, and left a red 
and annular surface, may be at first mistaken for a Lepra hav- 
ing its seat on the scalp, particularly if, as sometimes happens, 
there are some spots of the former on the body. But it is still 
more rare to see the Porrigo scutulata on the body and 
limbs, than to find the Lepra on the scalp, so that the error 
will soon be corrected. This variety of Porrigo, is consti- 
tuted of favose pustules, and in the commencing stage of the 
rings these will soon be perceived. It is useless to allude to 
all the differences between these diseases, as the presence and 
nature of the scabs, the alteration and destruction of the bulbs 
of the hair, for the contagious nature of the first will always 
suffice to separate them. 

The round form of the syphilitic diseases, may in some 
eases of tubercular Syphilide be a cause of mistaking them for 
Lepra, particularly when occurring on the forehead or back. 
But passing over the coppery and livid colour, the cicatrices 
that are almost always found in the vicinity of the eruption, 
the attendant symptoms, &c. ; if an attentive examination be 
made, it will be easy to see that it is not a continuous circle, 
but that it is composed of isolated tubercles, disposed in rings 
it is true, but having marked intervals between them; that 
these tubercles are prominent and smooth ; that they are not 
covered with scales, or at least in the rare cases in which 
these do occur, they are extremely thin and hard lamellae, al- 
ways smaller than the circumscribed induration which they 
surmount. In some cases where the tubercles are beginning 



248 SCALY DISEASES. 

to disappear, and are less prominent, they may readily be 
mistaken for Lepra in a healing stage, but the characters al- 
luded to above will always distinguish them. 

Finally, Lepra may be confounded with an eruption that 
has been latterly described under the name of Lepra nigri- 
cans, Will, and which is only a variety of scaly Syphilide. 
The black colour of the patches is fully adequate to mark its 
character. 

If we now compare Lepra with the diseases of the same 
order, we shall see that its marked symptoms are sufficient in 
most instances, to distinguish it at the first glance from the 
irregular patches of Psoriasis, which alone can be mistaken 
for it. Nevertheless, there is a variety of this eruption, the 
Psoriasis guttata, characterized by isolated patches, which 
in some cases, it is difficult to separate from Lepra, especially 
when in the healing stage. But the patches of the former are 
always smaller than those of the latter, are never as regular, 
their centre is always diseased, and has no depression, and 
even where in Lepra some parts of the circle have disappear- 
ed, those that remain will suffice to establish the diagnosis. 
Finally, in the cases of Lepra, where the spots are aggregated 
and confluent, by a little attention, portions of the different 
circles may be distinguished at the edges of the eruption, or 
even in the centre of the diseased surface; and on other parts of 
the body, a new patch in its commencing stage may be found, 
which will leave no doubt as to the nature of the eruption. 

Prognosis. — Lepra never occasions any danger; but in all 
cases it may be considered as very obstinate, and difficult of 
cure. 

Treatment. — The treatment of Lepra is composed of ex- 
ternal remedies, internal medicines and hygienic means. But 
in undertaking any plan of treatment, attention must be paid 
to the age and strength of the patient and the state of the dis- 
ease. 

If he is young, strong, and vigorous ; if the disease has 
made rapid progress; if the skin is red and inflamed, the pulse 
full and active; recourse must be had to blood-letting, simple 



LEPRA. 249 

baths, diluent drinks, a rigid diet, and rest. We here mean 
by blood-letting, venesection, for to attempt to apply leeches 
to the vicinity of the diseased parts, is impracticable in most 
cases, and never attended with any beneficial results. 

In feeble elderly persons, and in those whose constitutions 
are injured, or enfeebled by misery and privation, and where 
the eruption is little if any inflamed, tonics should be used for 
some time, before commencing an active treatment. These 
precautions having been taken, the disease itself may be at- 
tacked, by both external and internal remedies. 

If we except baths, which are such powerful auxiliaries in 
the treatment of Lepra, the external remedies, particularly 
those so much praised by the earlier writers, and which con- 
sisted of lotions, and applications, made up of irritating sub- 
stances, such as briony, calcined alum, &c. are always useless, 
and often attended with ill consequences; they may succeed 
in some rare cases where the disease is confined to very 
small surfaces. This remark also applies to the spirituous 
lotions, &c. and above all, to the ointments of resin, or tar, 
&c. which have been recommended in England* Indepen- 
dent of their real inefficacy, it may be readily conceived 
what would be the effect of topical applications of tar oint- 
ment, in those numerous cases, where the disease exists not 
only on the limbs, but also on the back, abdomen, &c. All 
these means, which are rather the fruits of speculation, than 
the results of practical experience, should be rejected, and 
with them blisters and caustics. 

Amongst the external applications, however, we will cite 
one which we have seen employed with great success, for se- 
veral months past in the Hospital of St. Louis, by M. Biett, 
in several diseases of the skin, and among others in Lepra; 
this is a resolving ointment, composed of ioduret of sulphur, 
gr. xii. to xv. and axunge li. The ioduret may be increased 
to half a drachm. This remedy may be used in recent erup- 
tions of Lepra in feeble individuals, who could not support 
an energetic treatment, but the success of this preparation, as 
we have seen exemplified, has led us to believe that it will 



250 SCALY DISEASES. 

hold a very high place among the therapeutic agents in the 
cure of diseases of the skin. Whilst the patient is at the 
same time on the use of a bitter decoction, frictions with this 
ointment are to be made night and morning, on several of the 
patches of the eruption; in a short time a greater degree of 
vitality is established, the skin inflames, the scales fall off, the 
elevations disappear, at the end of a few days, the resolution 
is complete, and the skin regains its natural state ; other dis- 
eased parts are then to be treated in the same manner. 

Baths are all more or less useful in the treatment of Lepra, 
but they are not sufficient of themselves, to produce a complete 
cure. Sulphurous baths, and those of sea- water, have been 
extolled, and with reason. They will, without doubt, advan- 
tageously modify the march and state of the eruption; those 
which act in the surest and most effectual manner, are the va- 
pour baths; they render the circulation more active, the skin 
becomes more natural, they induce perspiration, which de- 
taches the scales, underneath which it may also be perceived, 
but in much less quantity than on the sound skin. Sulphur- 
ous fumigations are far from being attended with the success 
that has been attributed to them; they only produce transient 
good, and even totally fail in a majority of instances. 

A disease so obstinate as Lepra, a disease which often occu- 
pies a great part of the surface of the body, cannot, (in most 
cases at least,) be combated with advantage by external reme- 
dies, which are generally useless, and very often inapplicable. 
Recourse must therefore be had to internal treatment, and the 
materia medica has furnished many energetic articles, to 
which a majority of cases will always yield. The pyramidi- 
cal elm, the Daphne mezereon and cnidium, the powder of 
hellebore, the Rhus radicans, &c. have each been extolled, but 
have not always merited the eulogies that have been bestowed 
upon them by practitioners, who have drawn their opinionsfrom 
far too few facts. Almost all these preparations are good aux- 
iliary means, some even induce a sensible amelioration, but 
rarely a complete cure, and from their uncertain action, their 
use has become much less frequent. 



LEPRA. 251 

The properties of the bitter sweet, ( Solatium dulcamara,) 
appeared to be verified in a much less vague manner. Extol- 
led in France by Carrere, it has been latterly introduced into 
England by Dr. Crichton, physician to the Westminster Hos- 
pital. The numerous experiments made by this practitioner, 
and which are given in some detail, in Willan's work, appear 
to prove that the stems of this plant have been employed with 
much advantage in certain cases of Lepra vulgaris. At the 
same time, similar trials, made first by Professor Alibert, and 
more lately by M. Biett, have not been followed with the 
same results. 

This plant, administered to a. considerable number of per- 
sons suffering under Lepra vulgaris, produced in some, a slight 
amendment; but in the majority, it was attended with no sensi- 
ble effects; two individuals only, who presented more favour- 
able conditions for its use, were entirely cured. In the great- 
est number of cases, M. Biett has remarked that when this 
plant was given in large doses, it occasioned a slight derange- 
ment in the mental faculties; at other times, it gave rise to 
nausea, and even vomiting. These symptoms do not appear 
to depend on an inflamed state of the gastro-intestinal mucous 
membrane. The bitter sweet should therefore be classed 
among- those remedies, which maybe useful under certain 
circumstances, but whose properties should be still further in- 
vestigated. 

Sulphur has acted as an useful auxiliary; antimony, and espe- 
cially its sulphuret, which appears to have produced advan- 
tageous results as a revulsant, has often failed; metallic mer- 
cury, and its deuto-chloride do not appear to have been more 
successful. Calomel has often produced good effects, but 
only as a purgative. Tar has been followed with various re- 
sults; the same may be said of the sulphureted sulphate of soda. 
There is scarcely any necessity to speak of viper broth, for- 
merly so celebrated. 

From numerous experiments made at the Hospital of St. 
Louis, for several years past by M. Biett, it appears that this 
disease may be treated with success, by three different me- 



252 SCALY DISEASES. 

thods. — I. By purgatives. 2. By the tincture of cantharides. 
3. By the arsenical preparations. 

It would be difficult to designate in an exact manner the 
cases where each method is to be preferred, as we often see 
purgatives succeed, where the tincture of cantharides has 
failed, and vice versa. Nevertheless, from a great number 
of facts, we have been enabled to establish some positive 
data. 

Purgatives. — This method succeeds best, says Hamilton, 
when the Lepra is recent, of little extent, and has appeared 
for the first time; it is the only one that is applicable to 
children. It consists in administering every morning before 
eating, sometimes a dose of calomel of four grains, sometimes 
a like dose of a mixture of equal parts of this mercurial prepa- 
ration with jalap. Sometimes it is sufficient to add a mild 
dose of some purgative salt, to a pint of bitter ptisan — two 
drachms, or half an ounce of sulphate of magnesia or soda for 
instance. At other times, recourse must be had to more active 
means, and aloes r extract of colocynth, resin of jalap and gam- 
boge, &c. either alone or combined, produce very good effects. 
But the choice of the purgative cannot be fixed a priori, it 
must vary according to the individual, to the state of the erup- 
tion, and above all, according to the effect produced. Calomel, 
however, is without doubt, that which succeeds the most often 
and promptly. It is not rare to obtain a complete cure in two 
months, or even in less, by the aid of this preparation, which, 
administered every day, in the dose of four grains, scarcely 
ever induces accidents. It is true, that in some cases it occa- 
sions a salivation, which obliges us to relinquish its use; but, 
whatever may be said, these cases are rare, when used in this 
dose. It is peculiarly beneficial in children, and may be given 
in the proportion suited to their age, mixed with a little su- 
gar. Whatever may be the remedy chosen, it should be 
borne in mind that it is not a sudden and sometimes danger- 
ous revulsion that is to be produced, but a slow and certain 
change of the system, hence the remedies to be continued a 
long time, should always be given in small doses, it is also ad- 



LEPRA. 253 

vantageous to intermit their use for two or three days at a 
time, during the treatment. 

Tincture of Cantharides. — When Lepra has reappeared 
after a greater or less interval, from the effect of some un- 
known cause, when it exists in persons of a delicate constitu- 
tion, when it occupies a large extent of surface, finally, when 
it has resisted purgatives, it sometimes yields in an astonish- 
ing manner to a well regulated employment of the tincture of 
cantharides. The patient is to be placed on a strict diet, and 
to take every morning three to five drops of this medicine in 
a tea-spoonful of ptisan. The state of the digestive and genito- 
urinary organs are to be closely attended to, and if they do 
not appear to suffer, the dose may be augmented five drops 
every six or eight days. If, on the contrary, it occasions much 
heat in the epigastrium, nausea, purging, ardor urinae, or 
priapism, &c. which however, are rare, the use of it must be 
suspended; but administered with prudence, and in a gradual 
manner, it may in general be raised to twenty-five or thirty 
drops, or more, without occasioning any unpleasant symptom. 
Often, and especially in females, a permanent cure will be ob- 
tained in forty -five or fifty days; and among other remarkable 
examples which have presented themselves to our observation, 
in the Hospital of St. Louis, we have seen a case of Lepra, 
which had lasted for eighteen years, and which disappeared 
in the space of a month by the use of this preparation. 

Arsenical remedies. — If Lepra has existed for several 
years, if it has involved almost the whole superficies of the 
body, if the skin is thick and altered, it will, in all probabi- 
lity resist the above mentioned methods. It must be attacked 
with the arsenical preparations, not that it is necessary before 
employing this remedy, to wait till the disease has attained 
this height, but very advantageous results have been obtained, 
where all other means have failed; it may even be said, the 
effect of this plan is almost certain. Among the various pre- 
parations, those which have been employed with the greatest 
advantage are Fowler's and Pearson's solutions. The latter 
has for its base, arseniate of soda in the proportion of one 

33 



254 SCALY DISEASES. 

grain to the ounce of distilled water; it is much less powerful 
than the first, but it is much more readily managed. It should 
be employed in women and debilitated persons; the dose at first 
is a scruple, which may gradually be raised to half a drachm, or 
even a drachm. Fowler's solution contains eight grains of 
arsenite of potash to the pound of water; it is one of the most 
powerful agents of the materia medica. It is to be given in 
the dose of three drops in some inert vehicle, in the morning, 
fasting, and every five or six days it is to be augmented two 
or three drops. It may be carried as high as twenty or twenty- 
five drops, but it is prudent not to go beyond this quantity, 
and often, as in the use of the tincture of cantharides, to inter- 
rupt its use from time to time, and when it is reassumed, not to 
recommence with the same quantities as were last given, but 
in decreased proportions. Sometimes this preparation will suc- 
ceed very well where Pearson's solution has failed. 

If symptoms of inflammation of the gastro-intestinal mu- 
cous membrane should supervene, these remedies should 
not be persisted in, but by paying strict attention to the 
state of the digestive organs, it would be criminal to re- 
fuse a patient the use of so precious an article on account 
of the chimerical fears of some irresolute practitioners. 
The arsenical preparations may be dangerous, it is true, in 
imprudent and inexperienced hands, but given with pru- 
dence, they will not on the one hand, occasion any unplea- 
sant symptoms, and on the other, they are attended with the 
greatest success. Here, for example, their effects are con- 
stant; these consist at first, of an increase of activity in the 
eruption; the patches become endowed with more sensibility, 
the centre heals, the edges split, gradually fade, and often, at 
the end of two months, a serious and inveterate disease which 
has lasted for years, will be seen to disappear. 

The Hygienic treatment alone, will not suffice to cure 
Lepra, but it is useful in completing the restoration to health. 
Thus, the patients should avoid all causes that might have had 
an influence in producing it, in many cases they should give 
up their profession. It is above all, indispensable that they 



psoriasis. 255 

should observe a strict diet, and renounce the use of spirituous 
liquors; they should also take baths, from time to time, to 
keep up and stimulate the functions of the skin. It has been 
from a want of these precautions that relapses have sometimes 
occurred, and which have been attributed to want of efficacy 
in the treatment. We have seen in the Hospital of St. Louis, 
habitual drunkards, or persons who exercised a profession which 
acted more or less on the development of the disease, remain in 
the wards two and three months after an entire cure had been ef- 
fected, without the least trace of a new eruption making its 
appearance, and yet return in a fortnight or three weeks after 
their having left the hospital, covered with patches of Lepra. 
The disease was evidently reproduced by excesses, or by the 
influence of their profession. 

Psoriasis. 

Psoriaris is derived from Psora, an old word formerly em- 
ployed in two senses: 1. For an ulceration of the skin, 
Tpaput x%a£e$ } which appears to belong to Impetigo; 2. ipapx, 
to designate the scaly affections. 

Psoriasis is characterized by patches of greater or less ex- 
tent, which are irregular, slightly elevated above the level of 
the skin, and covered with thin scabs of a chatoyant-white 
colour. It constitutes, if not several species, at least several 
distinct varieties, some from the form and intensity with 
which they present themselves, the others from their seat. 

A. From their form and intensity. — Sometimes the 
patches are separated, and of little extent; sometimes they are 
larger, confluent, and irregular; at others, again, they are very 
large, and form a continuous surface; finally, they may appear 
in the form of long spiral striae, thus constituting four princi- 
pal varieties; Psoriasis guttata, diffusa, inveterata, and 
gyrata. 

1st. Psoriasis guttata. — This may be considered an in- 
termediate species between Lepra and Psoriasis; it is charac- 
terized by small, rounded, irregular patches, more elevated 



256 SCALY DISEASES. 

in the centre than at the edges. At first — small, distinct, red 
spots appear, in the centre of which may soon be perceived a 
slight scale; the patches become circular, and extend, though 
nevermore than a few lines; they remain isolated, being separat- 
ed by healthy intervals, and somwhat resemble drops of some 
liquid sprinkled over the skin, (guttata. ) The scales are more 
or less adherent, and leave on their falling off, a surface which 
is oftentimes very red, somewhat painful, and prominent. 

They are observed on all parts of the body, but more parti- 
cularly on the posterior part of the trunk, and the external 
surface of the limbs. They are seldom accompanied with gene- 
ral symptoms, except that in the evening and night, the heat 
of the bed occasions a slight itching; and either from the action 
of the nails, or from a natural desquamation, the epidermic 
scales fall off, but are soon renewed. This variety is not rare; 
it is most generally met with in adults, and is comparatively 
a mild disease. 

2d. Psoriasis diffusa. — This manifests itself by patches of 
a much larger size, flat, angular, and very irregular. At the 
commencement there are also small separated elevations, a 
kind of red papulae, which soon become confluent; these do 
not assume the appearance of distinct scaly disks, but of 
large irregular surfaces, covered with scales of different thick- 
nesses and adherence. Although it may be seen on all parts 
of the body, it particularly attacks the limbs; it is not uncom- 
mon to see a single patch cover the whole anterior part of the 
leg, or the posterior part of the forearm; the elbows and knees 
are especially affected, and even when it has entirely disap- 
peared from other pails, it remains fixed in these spots, and 
resists every means of cure for a long time. 

In some rare cases, this eruption may present a multitude of 
patches on different parts of the body, and we have seen it at 
the Hospital of St. Louis, occupy a great part of the back, ab- 
domen, arms, even extending to the fingers, and forming on 
them a kind of case, which was partly raised; the edges were 
detached, and whiter than the centre, exhibiting under them 
red and polished surfaces. It is generally preceded by some 



PSORIASIS. 257 

general symptoms, as cephalalgia, uneasiness, troublesome 
itching, and sometimes intestinal pains; these symptoms soon 
diminish, and cease entirely on the appearance of the eruption. 
Sometimes, and indeed ordinarily, the patches are but little 
inflamed, and the patient only complains of a little tingling. 
But in some rare cases, the inflammation is more violent, the 
patches are more prominent, the scales are thicker, chaps and 
fissures occur, which sometimes are open and ragged, particu- 
larly where the eruption is very extensive, and encases the 
forearm, fingers, &c. 

This disease usually attacks adults, but may also be observ- 
ed in young children, (P. infantilis, Will. ) It is sometimes 
developed with extreme rapidity. At all events, this affection 
is very common, and often severe; it may last for years, and 
is often very obstinate under the best treatment. 

3d. Psoriasis inveterata. — This is the same disease, but 
in a more aggravated form. Either from having lasted a long 
time, and not having been submitted to any treatment, or 
that it has been irritated by causes constantly acting on it, 
or from being developed in elderly persons, and in those who 
are debilitated by misery, uncleanliness, or those who are ad- 
dicted to all kinds of debauchery; this variety may make a gra- 
dual progress, and acquire a great degree of intensity; the skin 
becomes thickened, or even in a state of hypertrophy , it is split 
in all directions, so as not to present scales, but a mealy sub- 
stance, which filling all the interstices formed by the numer- 
ous fissures, gives rise to a most abundant desquamation; 
in this stage of Psoriasis, the surfaces may even be entirely 
destitute of scales; they are red, but little inflamed, and 
furrowed in all directions. If the skin is attempted to be 
pinched, or to be raised between the fingers, it appears to be 
altered even in its lowest layers, and it leaves on the fingers 
the impression of a rough, unequal body. 

Sometimes the eruption is confined to the limbs; at others, 
it covers the whole body, and in such case, the patient appears 
to be enclosed in a scaly covering. The least movement occa= 
sions folds or rents in the skin, followed by a flow of blood, 



258 SCALY DISEASES. 

The nails become yellow, split, fall off, and are replaced by 
scaly, deformed incrustations. Sometimes the mucous tissue 
is affected, and symptoms of gastro-intestinal inflammation 
may occur; but on the contrary, and especially when the dis- 
ease appears in young and robust persons, the reverse takes 
place, and it seems as if the digestive organs had acquired an 
extraordinary activity. This is the most severe form of 
Psoriasis. 

4th. Psoriasis gyrata. — This variety consists in long, 
vermiform patches, assuming a spiral form, narrow, few in 
number, and generally occurring on the body. It is extremely 
rare, and has often been confounded with Lepra and Syphi- 
litic eruptions in their healing stage. M. Biett, under whose 
observation such multitudes of diseases of the skin have fallen, 
has only met with two or three examples of it. 

We have observed a vast number of intermediate states be- 
tween these four varieties, and which were allied more or less 
to some one of them; but it would be useless to enumerate 
them. Thus, for example, to speak of one which is remark- 
able, we have several times seen in young and light com- 
plexioned subjects, whose skin was fine and delicate, patches 
of a circular form, but neither elevated at the edges or the 
centre. The eruption consisted of one or more circles, almost 
always distinct, of the size of half a dollar, having an even, 
flat surface, covered with thin, light scales, which had but 
little adherence to a rosaceous base, which was also but slight- 
ly inflamed. These occurred on the body and arms. This 
variety corresponds very well with the Dartre squammeuse 
orbiculaire, Alibert. 

B. Varieties from situation. — Pso? , iasis presents some 
peculiarities in its seat, which it is important to notice, not 
only because it is often entirely local, but also because in the 
generality of these cases, it is attended with symptoms wholly 
dependent on the spot it occupies. 

Psoriasis ophthalmica. — This is characterized by small 
scales attached to the angle of the eyes or to the eyelids, which 
are swelled and impeded in their motions; it is remarkable 



psoriasis 259 

that this variety, although it often accompanies that of the face, 
sometimes exists alone, especially in children. It sometimes 
occasions a high degree of itching, and the disease often in- 
volves the conjunctiva, thus rendering its cure very difficult. 

Psoriasis labia lis.— This usually exists alone; it appears 
in the form of a circle completely surrounding the mouth, 
sometimes to the extent of half an inch, in every direction, 
(Dartre squammeuse orbiculaire, Al. ) This circle is fur- 
rowed by a multitude of lines, which, commencing at the cir- 
cumference, reach the lips, and give to these parts a corrugated 
appearance, that imparts a disagreeable aspect to the physiog- 
nomy. The epithelium is thickened, and the scales much 
larger than in the other varieties. It is in general very ob- 
stinate. 

Psoriasis preputialis. — The psoriasis of the prepuce often 
exists by itself; it may however accompany that of the scro- 
tum; it is characterized by a thickening of the folds of the skin, 
and by so great a corrugation as to occasion a phymosis; the 
least effort to uncover the gland is painful, and often follow- 
ed by a flow of blood. It is a long and painful disease. 

Psoriasis scrotalis. — This affection of the scrotum, and that 
of the labia pudendi in women, is rare, and the diseases that 
have been described as belonging to this genus have generally 
been chronic Eczemse. Nevertheless the P. diffusa may 
sometimes occur in these parts; the skin is then dry, rough, 
thick, and split; it presents fissures; the disease may even ex- 
tend to the penis, which becomes covered with a scaly enve- 
lope. As to the patches of P. guttata, that have been ob- 
served in this spot, they have frequently been confounded with 
syphilitic tubercles, of which these parts are so often the seat. 

Psoriasis palmaria, ( Dartre squammeuse centrifuge, 
Al.) — This variety at first manifests itself by a slight inflam- 
mation, and appears in the form of a solid, red elevation in the 
palms of the hands, and more rarely on the soles of the feet. 
Sometimes it is accompanied with smarting and great heat 
This elevation soon becomes covered with a white, dry scale, 
at times of some size; this falls off, and an eccentric layer 



260 SCALY DISEASES. 

takes place, and as the centre heals, the circumference extends 
till the disease may involve the whole hand. The uncovered 
centre assumes a livid colour; the scales remain hard, the skin 
thickens and splits, fissures occur, the palmar surfaces of the 
fingers are attacked and cannot be straightened, the least at- 
tempt inducing painful twitches. In women, this variety is 
sometimes complicated with that of the labia pudendi. 

It is a difficult disease to cure, and very subject to relapses; 
as it often occurs in individuals accustomed to hard labour, 
which causes a return of it, when they have been perfectly 
cured. 

Sometimes the Psoriasis is exclusively confined to the back 
of the hand, and gradually extends to the dorsal surface of the 
fingers; it presents larger, drier, and harder scales, and is com- 
plicated with deep and painful fissures at the articulations. 
This disease has been termed the Baker's itch. In fact, although 
it is observed in some rare instances in other professions, it 
usually affects people employed in this business, and those 
who are exposed to the action of pulverulent substances, as 
grocers, &c. It has been observed in washerwomen, occasion- 
ed by the constant irritation from the soap. 

Causes. — The causes of Psoriasis are quite as obscure as 
those of Lepra; it is never contagious, but it may be heredi- 
tary. It attacks both sexes, at all seasons, but especially in 
the spring and autumn. Although it may be observed in the 
midst of comfort, and even of luxury, it is more common to 
see it in the poor, the badly clothed, and unclean. Excesses in 
food, certain salted articles, sea-fish, &c. the mental affections, 
are all causes that may occasion it. Direct irritating agents 
may also act in a greater or less degree on the development of 
the local varieties.* 

Diagnosis. — It is sometimes very difficult to distinguish 

* Most writers on cutaneous disorders maintain that Psoriasis and the scaly 
diseases generally, are not contagious. Dr. Graves, however, relates, in the 
Dublin Hospital Reports, Vol. IV. that he has met with several cases which 
render it probable, that in some instances it may be communicated by long- 
continued contact. — Thans. 



PSORIASIS. 261 

Psoriasis from Lepra, especially as in certain cases this latter 
disease appears to change into the former. Generally, however, 
these two affections can be discriminated, if it be recollected 
that in Lepra the patches are large, rounded, depressed in 
the centre, and elevated at the edges, while in Psoriasis gut- 
tata, which is the form that w T ould usually be mistaken for it, 
the patches are small and have an elevated centre ; in P. dif- 
fusa, they are quadrangular, irregular and unequal; finally, in 
P. inveterata, there are large, furrowed surfaces, which may 
envelope a whole limb, &c. The form of P. gyrata, is always 
sufficient to designate it. 

One of the most common forms of the scaly syphilide may 
be taken for P. guttata. The syphilis sometimes manifests 
itself on the skin in rounded, isolated, prominent spots, but 
in Psoriasis they are of a vivid red, and covered with scales, 
whilst in the syphilitic disease they are of a copper colour, 
they are not covered with scales, or at least if so, they are ex- 
tremely thin, and besides there is always a constant pathogno- 
monic character, which M. Biett has often pointed out in his 
clinical lectures; this is a small, white band, analogous to that 
which succeeds to vesicles, that encircles the base of each ele- 
vation. 

Sometimes the remains of the patches of scaly syphilide, 
and especially syphilitic tubercles in their healing stage, have 
been taken for P. gyrata. But here, as in the preceding 
case, independently of the peculiar characters of each erup- 
tion, the colour and concomitant symptoms will suffice to cor- 
rect the error. 

The edges of the large patches of Lepra have often been 
taken for this last variety, but in making a careful examina- 
tion, it will be seen that these edges affect a circular form, 
portions of the rings will be observed, and in uniting the dis- 
joined parts, in idea, it will be perceived that they would have 
formed complete circles, very different from the curved lines 
that characterize the P. gyrata. 

The thickness of the scales, the presence of solid elevations, 
which are more or less prominent, will prevent those cases of 



262 SCALY DISEASES. 

Psoriasis which have their seat on the scalp from being mis- 
taken for Pityriasis; it however, is more difficult to distin- 
guish it from a chronic Eczema. Nevertheless, in the vesi- 
cular affection, yellowish scales are to be found, covering a 
surface which is usually moist ; and the constituents of the 
disease may generally be perceived in the vicinity. 

Psoriasis of the lips approaches more closely to the ap- 
pearance of Eczema when it presents chaps and fissures, 
which are generally to be seen in the chronic vesicular 
affections. Here the diagnosis should be based on the absence 
of vesicles, the size and hardness of the scales, and the thick- % 
ening of the epithelium. Various squamose affections may 
exist simultaneously ; thus, not only may patches of Psoriasis 
be seen in individuals affected with Lepra, but even many va- 
rieties of it on the same person. This affection may also be 
met with, although rarely, existing with eruptions of another 
order. We have seen a very remarkable case in the Hospital 
of St. Louis, where Psoriasis of the scalp existed with 
Porrigo favosa. 

Prognosis. — Psoriasis is generally a serious disease, par- 
ticularly from its obstinate duration. The prognosis, how- 
ever, varies according to the species, the length of time the 
disease has lasted, and the state of the patient. Thus the 
P. guttata, although less formidable, is very refractory; the 
P. diffusa is still more so, especially when it attacks old per- 
sons, or individuals debilitated by privations of all kinds. 
Finally, the P. inveterata is much less violent, although it 
often resists all curative means. 

Termination. — This disease may disappear without any 
treatment; the patches become paler, and diminish, and the skin 
regains its natural colour. At other times one species may 
turn into another. Thus P. guttata and diffusa may 
change to inveterata. 

In a majority of cases, when treated in a proper manner, it 
gradually heals; the scales fall off, are formed more slowly, 
and become thinner; the elevations are less and less red and 
prominent; the large diseased surfaces become intersected by 



psoriasis. 263 

intervals of sound skin. Finally, little by little, the epidermis 
every where regains its normal characters ; then resumes its 
pliability, and all that remains is a light tint on those places 
that have been occupied by the disease. 

In some more violent cases, the eruption resists all means; 
the skin gradually thickens, and becomes affected down to the 
cellular tissue; the nails themselves, as we have already ob- 
served, participate in the general alteration of the integuments. 
The disease continues for years, without inducing any serious 
symptom, but sometimes the patient perishes from a chronic 
inflammation of the gastro-intestinal mucous membrane. 

Treatment. — The treatment of Psoriasis is similar to 
that of Lepra, and all that we said when speaking of that dis- 
ease is applicable to this, except that as it is generally more ob- 
stinate, it more frequently requires the employment of energetic 
means, and particularly of the arsenical preparations. It has 
not been without surprize, at least to those who have seen 
Psoriasis cured by these means, that they have observed in 
a recent work, that the treatment of P. inveterata should be 
confined to narcotics and emollients. As for us, who believe 
that so violent a disease requires something more than the use 
of palliatives, and who think that it would be inhuman to leave 
an individual a prey to an affection which poisons his exist- 
ence, and will abridge his life, when we have seen it yield to 
this kind of treatment more than a hundred times; we do not 
fear to state, that by the aid of the arsenical preparations, per- 
manent cures may be obtained, and without fear of accidents, 
when they are properly administered, and also, that it is often 
the only remedy to oppose to the P. inveterata. This opi- 
nion is not grounded on specious theories, but is the positive 
result of a great number of facts. 

We should add in these cases, to Pearson's and Fowler's 
solutions, the use of a preparation which has always been of 
the greatest advantage in this disease; this is the Asiatic pills, 
which are formed of the protoxide of arsenic mixed with black 
pepper, in the proportion of fifty-five grains of the protoxide 
of arsenic to nine drachms of pepper, of which eight hundred 



264 SCALY DISEASES, 

pills are to be made; one of these is to be given every day? 
they each contain about the thirteenth of a grain of arsenic. 
They may be increased to two, but not beyond ; indeed, in 
most cases, one is sufficient. No precise limit, as to time, can 
be assigned for their use; this must depend on the state of the 
patient, and that of the eruption. But their employment 
must be given up, if at the end of fifteen or twenty days they 
do not appear to have produced any sensible amelioration. 
Where the contrary is the case, they may be continued for six 
weeks, suspending their use from time to time, and using the 
same precautions as in the employment of the arsenical solu- 
tions. 

M. Biett made a series of experiments on another prepara- 
tion of this mineral, in 1819 and 1820, which had not hither- 
to been used, the arsenite of ammonia; he administered it in 
the same doses and under the same circumstances as the ar- 
senite of soda, and obtained satisfactory results, particularly in 
several cases of P. inveterata. 

Whatever may be the method employed, there often re- 
mains at the close of the treatment, some refractory spots, 
especially about the articulations. In these cases, it is useful 
to excite the skin by some stimulating ointment. The proto- 
nitrate of mercury mixed with axunge, in the proportion of a 
scruple to an ounce, will usually succeed. The patient is to be 
anointed on the diseased spots night and morning. 

The local varieties, independently of general treatment, 
which should generally consist of purgatives, also require par- 
ticular remedies. 

In P. ophthalmica, it is often useful, especially at the com- 
mencement, to apply three or four leeches behind each ear, and 
at a more advanced stage, frictions with the ointment of the pro- 
tochloride of mercury should be made on the diseased spots, 
both in this and in P. labialis. Emollient local baths, as well 
as frictions with the above ointment, are generally very advan- 
tageous in P. preputialis. P. scrotalis is often successfully 
combated by sulphurous fumigations. Sometimes fumiga- 
tions with cinnabar may be attended with happy results. 



PITYRIASIS. 265 

In P. pahnaria, after having softened the surfaces by local 
baths of scalded bran, &c. recourse may be had, with much 
advantage, to slightly stimulating and resolving ointments. 
The iodurets of mercury will fulfil this indication in a very 
satisfactory manner. ( Proto-ioduret of mercury, gr. xii. to 
9i. or Deuto-ioduret, gr. xii. to xv. and axunge, ^i. ) In this 
last variety, resort must often be had to the arsenical prepara- 
tions. The ioduret of sulphur may also be very advantage- 
ously used in these local eruptions. All these general and 
looal remedies should be aided by the use of baths; vapour 
baths or douches in the local varieties, are preferable to all 
others, with the exception of P. scrotalis, which is usually 
more promptly benefited by certain fumigations. 

Pityriasis. Dartre furfuracte volante, Al. 

The word Pityriasis, which comes from 7riTvpov, furfur, 
was employed by the Greek physicians to signify a farinaceous 
exfoliation of the epidermis. It is a chronic inflammation of 
the skin, in which the epidermis throws off small, white 
scales, which are extremely thin, and are detached and repro- 
duced with astonishing facility, and in great abundance. 

It may occur on all parts of the body, but is most generally 
observed on the head and those parts furnished with hair. 
Thus the scalp, the eyebrows, and the chin, are frequently its 
seat. 

Symptoms. — It is difficult to follow its development, and 
it is only known by the presence of small scales. It is never 
accompanied by any other symptom than that of violent itch- 
ing; the patient scratches, and occasions the disengagement of 
scales, which are almost immediately replaced, and no in- 
flamed point is perceived on their falling off; on the contrary, 
if a small scale is raised with the nail, which is easily effected, 
there is often a soft point found underneath; on scratching 
this, another small scale may be raised analogous to the first, 
and sometimes several may be thus successively detached, 
without arriving at an inflamed surface. But however this 



266 SCALY DISEASES. 

may be, a multitude of extremely thin, small, dry, white la- 
mellae may be perceived on the skin, usually adhering at one 
extremity, and detached at the other; they are not scattered here 
and there, but occupy a large space; they resemble an envelope, 
which had been split and divided, until it was reduced to very 
thin and small laminae. The least movement gives rise to a 
most abundant furfuraceous desquamation. 

Sometimes this exfoliation is composed of small portions of 
epidermis, similar to bran; on the chin for example, merely 
passing the hand over it, will occasion their disengagement; 
in a few moments they are replaced by others. On the scalp, 
on the contrary, the scales are larger; they sometimes are of 
the size of a small bean, and which they somewhat resemble 
in shape, except in being perfectly flat. 

Causes. — The causes of this disease are difficult to under- 
stand. On the head, it sometimes coincides with a want of 
development or activity in the bulbs of the hair. It is often 
observed in infants whose hair has scarcely appeared, and in 
the aged, where this has fallen out; in these cases, it is perhaps 
occasioned by the action of the hair, causing a slight inflam- 
mation of parts which are not yet, or which are no longer suf- 
ficiently protected. On the chin, it is often induced, and still 
oftener kept up, by the action of shaving. Sometimes it has 
been seen to arise spontaneously over the whole body in con- 
sequence of a violent affection of the mind. 

Diagnosis. — The size and prominence of the patches in 
Pso?*iasis, the form of those of Lepra, as well as the strongly 
marked characters of these diseases, will prevent the slightest 
difficulty in distinguishing them from Pityriasis. The farina- 
ceous exfoliation in this affection, can scarcely be confounded 
with the furfuraceous desquamation that is sometimes the se- 
quel of other cutaneous inflammations. Thus, in the desqua- 
mation that occurs after certain exanthematas, they are not 
small portions of epidermis, which are immediately replaced 
by others, but large surfaces which become bare at the same 
moment, and which exhibit extensive portions of sound skin, 
surrounded by a whitish and regular band, which forms the 






PITYRIASIS. 267 

line between the sound cuticle and the diseased surface. Be- 
sides, the concomitant symptoms will obviate all error. 

A desquamation sometimes takes place after chronic Ecze- 
ma and Lichen; but the vesicles of the one, the papulae and 
thickening of the skin in the other, will be sufficient to discri- 
minate between them ; added to which, the exfoliation is very 
different, and the scales are replaced by others, as in Pity- 
riasis. 

The size, irregularity, and above all, the colour of Ephelides, 
and of other alterations of that kind, which have erroneously 
been made varieties of Pityriasis, are easily distinguishable. 
Finally, this disease will not be confounded with Ichthyosis 
simplex, which might be mistaken for it 3 if it is recollected 
that in the latter case the disease is confined to a mere altera- 
tion of the epidermis, but that the skin is more or less affect- 
ed; that it is rough, thick, and harsh to the feel; that in Pi- 
tyriasis, on the contrary, it is rather softened ; that the scales 
have a grayish appearance, whilst they are white in Pity- 
riasis; that the one is, in a majority of cases, a congenital 
disease, and the other occurs accidentally. 

Prognosis. — Pityriasis may sometimes exist with other 
chronic inflammations; it is often a disease of long duration, 
but never severe. When it terminates, the itching becomes 
less violent, the desquamation less abundant, the scales are 
formed more slowly, and little by little the epidermis loses its 
chapped appearance, and regains its natural state. 

Treatment. — Bitter ptisans, rendered laxative by the ad- 
dition of sulphate of soda, in the proportion of half an ounce 
to the pint, or else subcarbonate of potash in dose of one to 
two drachms; alkaline lotions on the affected parts; alkaline 
baths, sometimes vapour douches are the means by which this 
slight affection may be treated. When it is seated on the chin, 
the beard should be cut with scissors — not with a razor. 

In children, it is often of so little consequence, that it is 
sufficient to merely brush the head lightly; the skin being 
thus irritated, becomes excited, and the exfoliation ceases. 



268 SCALY DISEASES. 



Ichthyosis. 



Ichthyosis has been arranged by Willan and Bateman among 
the scaly diseases, and there is no doubt but that it presents 
some symptoms which are similar to those of the affections of 
this order; but it also differs from them in many respects. 
Thus this disease does not consist merely in lamellae of epi- 
dermis, either altered or thickened, but it is evidently an or 
ganic lesion of the dermis, which is deep-seated, and possesses 
peculiar characters. Nevertheless, as the order of the scaly 
diseases is only based on external appearances, and as these 
appearances also appertain to Ichthyosis, which manifests itself 
by scales, we have thought it right to class it in the same man- 
ner as those pathologists. Besides which, in the actual state 
of the science, it would be very difficult to establish, why it 
could not belong to this order as well as Pityriasis, which is 
unaccompanied by any heat, any morbid congestion, and 
whose small scales, on being removed, discover little or no 
signs of redness. 

Professor Alibert has divided Ichthyosis into three species: 
1st. Ichthyose ?iacr6e, of which he makes two varieties, from 
its resembling either the skin of fish or of serpents, Ichthyose 
nacrie cyprine and Ichthyose nacr&e serpentine; 2d. Ichthyose 
cornee, which is characterized by an entire degeneration of the 
skin, and of which he distinguishes three varieties by their 
forms, Ichthyose cornee epineuse, Ichthyose cornee onguleuse, 
and Ichthyose cornee ariitine, (the excrescences of which re- 
semble the horns of a ram;) 3d. Ichthyose pellagre, a peculiar 
disease, unknown in France, and which reigns epidemically 
in the plains of Lombardy. We shall treat of this hereafter. 
Ichthyosis is characterized by the development, on one or 
more parts of the skin, and generally on the whole of it, of 
scales of different sizes, which are hard, dry, of a grayish- 
white colour, somewhat imbricated, formed of thickened epi- 
dermis, never resting on an inflamed surface, and unaccompa- 
nied with heat, pain, or itching, and constantly attended by a 
morbid alteration of the subjacent layers of the skin. 



ICHTHYOSIS. 269 

Ichthyosis may develope itself on all parts of the body, but 
the palmar surface of the hands, the soles of the feet, and all 
those regions where the skin appears to be most fine and de- 
licate, as the internal surfaces of the limbs, the arm-pits, groin, 
the face, and especially the eyelids, are less frequently attack- 
ed, and even when the disease is almost general, these parts 
remain uninjured, or only become the seat of attack at long 
intervals, and in a less degree. We have seen a child of 
twelve years of age, who was under the care of M. Biett for 
a long time, who was suffering from a congenital Ichthyosis, 
occupying the whole body, but whose face was entirely free 
from disease; but a most remarkable phenomenon took place 
in him; when he experienced the least irritation of the diges- 
tive organs, (which often occurred, notwithstanding a strict at- 
tention to his diet,) or even of any internal part, his face be- 
came of a sallow hue, and was covered with small, grayish, dry 
scales, the skin was also slightly thickened; these were much 
thinner than those that covered the rest of his body, which, on 
the contrary, were hard, large, and dark-coloured, &c. : this gave 
him a most peculiar aspect, resembling that of a little old man. 
Gradually, as the inflammation of the digestive organs de- 
clined, these scales detached themselves by degrees, the face 
regained its natural condition, and the eruption entirely disap- 
peared from it, there only remaining an habitual but slight 
thickening of the skin; no change was perceptible at these 
times in the scaly covering of the rest of the body, which was 
almost universal. This little patient was well grown for his 
age, and enjoyed tolerable health, except that the slightest 
deviation from his regimen, excited an irritation of his diges- 
tive organs. 

Ichthyosis generally manifests itself, and the morbid enve- 
lope is much thicker, on the external surfaces of the limbs, par- 
ticularly at the articulations, at the knees, elbows, neck, on 
the posterior and superior part of the body, and where the 
skin is naturally thick. It is usually general; sometimes, 
however, it is confined to one region, this is often the case 
when it is accidental. We have seen it several times at the 

35 



270 SCALY DISEASES. 

Hospital of St. Louis only occupying the arms or legs, for 
the accidental form of the disease ordinarily affects the limbs. 
But it is almost always congenital, and remains during the 
whole life of the patient; that which is accidentally developed 
may also last for an indefinite period; sometimes, however, it 
disappears, and in such case its duration varies from several 
months to many years. Congenital Ichthyosis is seldom strong- 
ly marked at birth, but the skin instead of presenting that fine- 
ness and polish that is observable in newly-born infants, is 
dry, thick, and rough; gradually, as the child grows, the dis- 
ease becomes characterized, and may assume different appear- 
ances. Sometimes the skin, although altered and slightly thick- 
ened, remains soft; it is covered with small scales of epi- 
dermis, which are unequal and grayish, and the disease ap- 
pears to be confined to a peculiar kind of dryness, accompani- 
ed by a continual farinaceous exfoliation, and a slight thicken- 
ing of the skin. This state corresponds to the Ichthyose na- 
cree serpentine, Al. According to this author, this variety 
almost always attacks old persons; it is true that in some indi- 
viduals advanced in years, the skin being withered and fur- 
rowed, presents a somewhat analogous roughness, but this is 
not a real Ichthyosis, as it wants all the essential characters — 
the presence of scales. 

At other times, Ichthyosis is accompanied with much more 
severe symptoms, which are violent in proportion as the pa- 
tients advance in years. The skin is thick, furrowed, and 
covered with real scales, which are dry, hard, resisting, and 
of a gray colour, sometimes, however, of a pearly-white, often 
shining, and in some cases surrounded by a kind of blackish 
circle. These scales are formed of thickened epidermis, which 
being fissured in all directions, is divided into a multitude of 
small, irregular portions, of different sizes, detached in the 
greater part of their circumference, and slightly imbricated at 
their point of adhesion. Some are small and surrounded by 
a great number of small farinaceous points, which correspond 
to the furrows which almost cover the epidermis; others are 
larger and cover these furrows. These scales may be remov- 



ICHTHYOSIS. 071 

ed, without occasioning the least pain, with the exception of 
the larger, which being more adherent are detached with more 
difficulty and occasion a sensation, which, if not absolutely 
painful, is at least disagreeable. They never expose a red sur- 
face on their removal. They sometimes occasion such a de- 
gree of roughness, that in passing the hand over the skin, it 
gives the same feeling as apiece of shagreen, and even in some 
cases it resembles that produced by the back of a fish, (Ich- 
thyose nacree cyprine, Al.) The scales are particularly ap- 
parent and thick on the limbs, at the anterior part of the knee- 
pan, the elbow, and the external faces of the legs and arms. 

Whatever may be the extent of this scaly covering, which 
sometimes extends over the whole body, or whatever may be 
its thickness, it never occasions any great change in the sys- 
tem or derangement of the functions; it is never accompa- 
nied by any pain, or itching; the skin, however, is no longer 
the seat of insensible perspiration; this in some cases is wholly 
wanting, in others on the contrary, it is said that this function 
exists in certain parts, and is even very abundant. This may 
perhaps be the reason, that in most instances, the soles of the 
feet are exempt from scales, from their being habitually moist 
from perspiration. Congenital Ichthyosis rarely undergoes 
any changes; sometimes, however, this happens, but most 
generally in the accidental forms, which at certain epochs and 
seasons, or under the influence of an inflammation of some in- 
ternal organs, really undergoes some modifications ; the scales 
become thinner and softer, the skin less arid and rough, &c. 
But at a later period, as the return of the season at which it 
first appeared, the disease is again produced, with all the cha- 
racters which had but disappeared for a short time. 

Dissection. — A careful examination of the organs of indi- 
viduals who have died whilst labouring under this disease, 
does not present any pathological alteration, which appears to 
be dependent upon it ; in the small number of cases, in which 
these researches have been made, appearances have been met 
with, wholly different from those that could have been occa- 
sioned by the cutaneous disease; as to the skin itself, not only 






272 SCALY DISEASES. 



is the epidermis found thickened and divided into a multitude 
of small scales, which are easily detached, but it may also be 
seen that they penetrate beyond the superficial layers, and ap- 
pear to depend on a deeper alteration of this membrane. 

Causes. — Ichthyosis may be congenital or accidental. Con- 
genital Ichthyosis often appears to be hereditary; at other times 
it seems to depend on some strong mental impression re- 
ceived by the mother; accidental Ichthyosis, and especially 
partial Ichthyosis may be attributed to the influence of exter- 
nal causes; thus according to Alibert, it is endemic in some 
countries, manifesting itself particularly in those which are 
contiguous to the sea, where it may be determined by the in- 
gestion of putrid fish, stagnant and brackish water, and by the 
constant humidity that surrounds the inhabitants of these 
countries; nevertheless, as this disease has been observed in 
individuals under entirely different circumstances, both as to 
their food and habitation, there still exists a great obscurity on 
the causes of accidental Ichthyosis, which may, it is said, be 
occasioned by fear, a fit of anger, violent grief, &c. It at- 
tacks both sexes, but we have more generally seen it in men. 
In more than fifty cases that have been admitted into the Hos- 
pital of St. Louis, or who have attended the dispensary at- 
tached to that institution, M. Biett has found the proportion 
of females to males was one to twenty. 

Diagnosis. — General Ichthyosis, and especially that which 
occurs with large and hard scales, presents itself with charac- 
ters of sufficient distinctness, never to be confounded with any 
other disease of the skin; as to partial Ichthyosis, and parti- 
cularly that in which the epidermis is divided into extremely 
thin and small lamellae, and appears in the form of an almost 
farinaceous exfoliation, it may be taken for the desquamation 
that succeeds to certain inflammations of the skin, and above 
all, for that which is frequently observed after Eczema or 
Lichen, if the dryness of the diseased surfaces, the hardness 
of the scales, small as they are, the grayish tint of the skin, 
and especially its thickness, were no{ characters sufficient to 
obviate all error; besides the origin of the disease, the absence 



ICHTHYOSIS. 273 

at the beginning of those elementary lesions which character- 
ize the vesicular and papular affections, will greatly aid the 
diagnosis. 

Prognosis. — Congenital Ichthyosis is beyond the resources 
of the art, which can only oppose it with palliatives, to cor- 
rect the inconveniences that result from the great dryness of 
the skin. Its prognosis, however, is not fatal, as it is sel- 
dom accompanied with any alteration of the internal organs, 
and those persons attacked with it, usually enjoy a good state 
of health. 

Accidental and local Ichthyosis, which always is less severe, 
may however, be very obstinate and last for life ; it neverthe- 
less appears to have been sometimes successfully treated. 

Treatment. — From what we have said, it is easy to per- 
ceive that the only treatment of congenital Ichthyosis consists 
in palliatives, which are wholly external ; thus mucilaginous 
lotions, repeated baths, and particularly those of vapour, may, 
in some cases, be of great use, in modifying the rough- 
ness of the skin, by slightly exciting its vitality. Several 
remedies have been recommended for the accidental forms; 
among others, Willan has highly praised the internal adminis- 
tration of tar, by means of which he restored the skin to its 
natural condition. We have seen several analogous cases in 
the Hospital of St. Louis, where this as well as other reme- 
dies were unattended with success. The only advantageous 
results that were obtained, were owing to external applica- 
tions, as emollients and baths. 

We do not think it proper to give an account of those acci- 
dental productions of various forms and dimensions, which 
are developed on the surface of the skin, and which Alibert has 
arranged "with Ichthyosis under the names of Ichthyose cornee 
epineuse, onguleuse, and arietine, according as they were co- 
nical and pointed, or curved in the shape of horns, &c; these 
morbid growths are no doubt sufficiently curious to be men- 
tioned in the history of the art, but do not belong to a work 
which is essentially practical, particularly as they are gene- 



274 SCALY DISEASES. 

rally beyond the resources of medicine, and any treatment 
that can be applied must be surgical. * 

* Professor Francis has given an extremely interesting paper on this dis- 
ease, in Vol. 2. p. 257, Am. Journ. Med. Sci. in which he gives a detail of 
several cases, accompanied with a plate of a singular form of the eruption. 
— Tbasts. 



( 275 ) 



ORDER VII. 

TUBERCULAR DISEASES. 
TUBERCULA. 

THE diseases arranged in this order are characterized by 
small, solid, persistent, circumscribed tumours, which are 
more or less voluminous, and always being primary affections, 
differ from the indurations we have spoken of, as succeeding 
to certain pustules, and constitute a very remarkable elemen- 
tary lesion. 

These small tumours have received the name of tubercles, a 
denomination which, as received in cutaneous pathology, is 
taken in its true sense, and is far from meaning the same kind 
of affection as is generally described under this name. 

The real tubercular diseases are seldom seen, at least in 
France; but the case is very different in tropical countries, 
where they are exceedingly common. 

They are three in number — Elephantiasis Grascorum, 
Frambcesia, and Molluscum. These are the only genera 
we have thought could be adopted of all those mentioned by 
Willan and Bateman; the others are, in fact, either pustular 
inflammations, which we have already described, (Acne, Sy- 
cosis, fyc.J or real alterations of texture, which not only can- 
not be included under the head of tubercles, but are even out 
of place in a work of this nature, (Phyma, Verruca,) or else 
they are diseases which consist in a true decoloration of the 
skin, ( Vitiligo,) or even a serious affection, which can neither 
be arranged with tubercles, or with any of the orders; this is 
Lupus, (Dartre rongeante, Al. ) which sometimes com- 
mences, it is true, by circumscribed indurations, but also may 
appear with very different .symptoms. 



276 TUBERCULAR DISEASES. 

As to the Noli me tangere, which, under the name of 
Cancer is classed in a recent work, among the tubercular in- 
flammations, it appears to us to be a peculiar disease, wholly 
different from those which belong to this treatise, and which 
seems to have nothing in common with diseases of the skin, 
but its seat. We have thought it right to leave it in the do- 
main of surgery, to which it properly belongs, and shall only 
speak of it in the diagnosis of Lupus to distinguish it from 
that affection. The tubercular diseases are all chronic, are 
developed in a slow manner, and last months, or even years. 

Symptoms. — The tubercles are usually red in Frambcesia; 
reddish, or sometimes without change of colour in Mollus- 
cum; and livid in Elephantiasis; they are of very variable 
size, being sometimes as small as a pea, and sometimes exceed- 
ing an egg in volume. Though usually distinct and isolated, 
they may nevertheless be united in groups, as in Frambcesia 
for instance, where they occur in bunches. Rarely accompa- 
nied with general symptoms, except in Elephantiasis, which 
is often complicated with a chronic inflammation of the mu- 
cous membranes, and particularly those of the digestive canal; 
the tubercular eruptions are most generally confined to parti- 
cular spots. Under some circumstances, however, they may 
become general; they may remain stationary, and then either 
disappear by resolution, or ulcerate at their apex and become 
covered with scabs. These crusts detach themselves after a 
certain time, leaving ill-conditioned ulcers. At other times 
there may be slight excoriations, and a formation of a partial 
exudation, which gives rise to dry, thin, but very adherent 
incrustations. 

Causes. — The causes of the tubercular affections are very 
obscure; they are all very rare in France; some of them, how 
ever, are very abundant in tropical regions. The Frambcesia 
and one variety of Molluscum may be transmitted by con- 
tagion. 

Diagnosis. — As will be seen in the particular description 
of these diseases, they present such peculiar characters, that 
they differ not only from eruptions of other orders, but also 



ELEPHANTIASIS. 277 

from each other, in a very distinct manner. To them alone 
belong small, solid, persistent tumours of different sizes, &c. 
elementary lesions that can never be mistaken. There is, it 
is true, a variety of Syphilis, in which it manifests itself by 
tubercles; but there exists marked differences between these 
two affections, both in the form of the eruption, the colour 
and march of the eruption, as well as in the totality of the 
symptoms. 

Prognosis. — The tubercular diseases are generally severe; 
this generally arises from their duration, and their obstinacy 
in resisting all curative means. The Elephantiasis is parti- 
cularly violent, not only by its effects on the system, but by 
the diseases with which it is complicated, which sometimes 
resist all remedies, and often occasion death. 

Treatment. — As all these affections are very rare in France, 
and as they have been but little studied in the countries in 
which they occur, there is much obscurity attending their 
treatment; that which is best known among them is Ele- 
phantiasis. For the cure of this, a host of remedies have 
been tried ; it is often obstinate, and requires very energetic 
means, particularly if, (as but too often happens,) the treat- 
ment is not commenced until the disease has made considera- 
ble progress. 

Elephantiasis Gr^corum. Lepre tuberculeuse. Leon- 
tiasis. Satyriasis. 

Alibert has described this disease under the name of Lepre 
tuberculeuse, and it especially corresponds with the first va- 
riety, Lepre tuberculeuse leontine, (Lepra tuberculosa 
leontiasis;) the second, Lepre tuberculeuse elephantine, 
(Lepra tuberculosa elephantiasis,) rather appertaining to 
the Barbadoes disease, (Elephantiasis of the Arabs.) 

Elephantiasis grsecorum is characterized by tubercles, 
which are prominent, irregular, soft, and red or livid at their 
commencement, but afterwards presenting a fawn or bronze 
colour; at times they are indolent, but at others, on the con- 

36 



27S TUBERCULAR DISEASES. 

trary, are painful on being touched. These tubercles being 
accompanied with a swelling of the subcutaneous cellular tis- 
sue, often give a hideous appearance to the parts on which 
they occur. This disease may manifest itself on all parts of 
the body, but is more generally to be seen on the face, and espe- 
cially on the ears and nose; on the limbs, and particularly the 
lower extremities. Sometimes it is confined to a single re- 
gion, at others it is almost general. It seldom attacks the 
body, even in those cases where it has made great ravages on 
the face and limbs. 

Its duration is generally very long, and even indefinite ; 
sometimes, however, it disappears in a short time, particularly 
where it is only constituted of a few tubercles, and on its 
first attack; but it may return again, and with tenfold vio- 
lence. 

Symptoms. — The appearance of tubercles is usually pre- 
ceded by light spots of a different colour in blacks than in 
whites; in the first, they are darker than the rest of the skin, 
and usually fawn-coloured or reddish ; in the latter, the tuber- 
cles soon appear, sometimes very rapidly and at others 
in a slow manner, in the form of small, soft, reddish or livid 
tumours, of a size which varies from that of a pea to that of a 
nut, or even larger. The skin at this time may become so 
sensible, that we have known patients, who, on being touched, 
even in spots where no tubercles existed, said that they felt a 
pain which they compared to that which is experienced from 
a contusion of the cubital nerve, when the elbow is struck. 
These tubercles, as we have said, are usually developed on 
the face, and often occasion a general tumefaction. 

Sometimes they are confined to a very limited surface , 
thus we have seen them only occupy the nose or the ears; in 
these cases the subjacent cellular tissue was in a state of hy- 
pertrophy, and these parts acquired an enormous size, present- 
ing unequal, deformed tumours, giving a hideous expression 
to the face. The eruption may, on the contrary, be confined 
to the legs, in which case it generally occupies the inferior 
part of the thigh or about the ankles, in the latter instance it 
is frequently accompanied with an ccdematous swelling. 



ELEPHANTIASIS. 279 

The disease may remain stationary for a long time; but it 
also may make rapid progress; it is no longer a few tubercles 
scattered here and there, but the whole face becomes covered 
with knotty tumours, separated from each other by deep fur- 
rows. There is a horrible change in the features, the nostrils 
dilate, and mishapen tubercles are developed on them; the 
ears become immense, the lips are swelled, the eyelashes and 
eyebrows fall out, the skin assumes a general bronze hue, 
which extends to the adjoining mucous membranes. The 
limbs are deeply furrowed, shining and unctuous, covered 
with enormous flat tumours, particularly on their external 
faces. The subjacent cellular tissue is swelled, and these parts 
often present a disgusting and repulsive appearance. The 
sensibility, which was so acute, now becomes quite ob- 
tuse, or may entirely disappear; the voice is weakened; the 
sight fails, smell is but excited by the most powerful stimu- 
lants, and the touch is almost destroyed or else is strangely 
defective. 

The general state of the patient also undergoes an alteration, 
he is depressed, loses his moral energy, and falls into a state 
of utter listlessness and apathy. As to the libido inexplebilis, 
which according to some authors, almost always accompanies 
this disease, we have never met with it in the few cases we 
have had occasion to see in the Hospital of St. Louis. 

But this disease may appear with characters of even more 
violence than the foregoing ; the tubercles inflame, they be- 
come the seat of ill-conditioned ulcerations, and are bathed in 
a sanious discharge which concretes and forms adherent, 
blackish, thick crusts. These often leave scars, and may be 
a favourable termination of the eruption, if it is confined to 
small surfaces; but when all the body is covered by it, it can 
readily be supposed what a horrible appearance an individual 
labouring under this hideous disease must present. 

But it is generally circumscribed, and accompanied with 
an extreme susceptibility of the mucous membranes. It is 
often complicated with Ophthalmia, and at a more advanced 
stage with Iritis. We have seen a patient, in whom the 



280 TUBERCULAR DISEASES. 

cornea of each eye was surrounded by a turgid circle, similar 
to that observable in Chemosis, except that it presented a 
fawn-coloured tint, resembling that of the skin. The func- 
tions essential to life are usually uninjured, the patients expe- 
rience no pain, except in such cases of extreme severity as 
we have alluded to above, and which soon put an end to their 
existence. 

Dissection. — The pathological alterations observed in those 
who have fallen victims to Elephantiasis 7 are very variable; 
they are in a great measure dependant on the duration of the 
disease, and the violence with which it attacked the different 
organs. 

The integuments, as we have already said, are studded 
with tubercles of different sizes ; some appear to be developed 
in the dermoid tissue itself, others are the result of inflamma- 
tion of the subjacent cellular tissue; this inflammation appears 
several times on the same spot, and leaves a tubercular indu- 
ration, of a whitish colour, and firm consistence. The skin 
which covers these indurations, is usually thin and shrivelled. 
The mucous system is also the seat of alterations ; that of 
the lips and conjunctiva is sometimes thickened and changed 
in colour. The mucous tissue of the tongue is often thick 
and split; that lining the palate, presented, in most of the 
cases examined by M. Biett, tubercles which were in groups, 
ulcerated at their summit, and extending over the uvula; 
in several individuals whose voice had been much altered, 
the mucous membrane of the larynx also was studded with 
tubercles, either in the lateral ventricles, or on the dupliea- 
tures that cover the vocal ligaments. In a young man from 
Gaudeloupe, who fell a victim to this disease, the arythe 
noid cartilages were even found carious and in great part de 
stroyed. The gastro-intestinal mucous membrane is almos 1 
always in a diseased state in those individuals who die of thi 
affection. In the greatest number of cases this consists in ul 
cerations of the ileum, the ileo-ccecal valve, or colon, whic 
inevitably cause death. These ulcerations sometimes tak 
place on tubercles which have been formed there at differer 






ELEPHANTIASIS. 281 

times, and at others on the follicles of Peyer. Other subjects 
presented morbid appearances in the lungs ; in many, tuber- 
cles* were found in different states of development, some ul- 
cerated, the others in a forming stage. Alibert relates several 
analogous cases in his great work, and M. Biett has also ob- 
served the same lesions in an individual from Guyana, and 
also in a person who had been in India several times. 

Tubercles similar to those of the lungs, have been disco- 
vered in the mesentery by Larrey, who has also detailed, in an 
interesting case published some time since, some pathological 
alterations he had observed in the liver. 

Alibert and Ruette have likewise seen the bones in a soft 
spongy state, and deprived of their medulla : in fact, it may 
readily be supposed that so violent a disease, implicating as it 
does all the tissues, can also alter these parts. As the greatest 
part of the pathological researches as regards this disease, 
have been made by physicians in Europe? and particularly by 
Schilling, Valentin, Raymond, Alibert and Biett ; it is very 
desirable that they should be repeated by practitioners in 
tropical countries, where this disease generally exercises its 
ravages. 

Causes. — Elephantiasis is an uncommon disease in France, 
and most of the individuals who are seen suffering from it, 
have been attacked in warm countries; it is, however, fre- 
quently to be met with in Gaudeloupe, St. Domingo, the Isle 
of France, &c. It has been said that it is contagious, heredi- 
tary, and even that it was a secondary syphilis. These opi- 
nions are far from being confirmed by experience; it appears, 
however, that it may be hereditary: Alibert states that he has 
seen two women in the Hospital of St. Louis, who had thus 
received the disease from their parents. But this does not 
always occur, as has been shown by a number of examples: 
M. Biett had the care of a lady from the West Indies, who 
was afflicted with a high degree of Elephantiasis; she had 



282 TUBERCULAR DISEASES. 

none of whom was there the slightest trace of this affection; 
on the contrary, they enjoyed the most perfect health. As 
to its contagious or syphilitic nature, well -authenticated facts 
have fully proved that such an idea is imaginary. 

Independently of general causes, some more direct agents 
appear to exert a marked influence on the appearance of this 
disease; it attacks both sexes and all ages, though it is less fre- 
quently seen in children. 

Low r , damp spots, the vicinity to marshes, and the use of 
salt meats, may all excite its development; in some countries 
it is generally attributed to the use of hog's flesh. In per- 
sons who have already been attacked, or who are predisposed 
to it, its appearance seems to be hastened by great fatigue, by 
the cessation of an habitual discharge, abuse of spirituous li- 
quors, and by violent mental affections. This latter cause, if 
we are to believe a learned pathologist, in acting on a preg- 
nant woman, has occasioned Elephantiasis in the foetus. 

Diagnosis. — The vagueness that has necessarily resulted 
from the same denominations having been given to different 
diseases, has for a long time thrown some obscurity over three 
affections, which are essentially distinct in their nature and 
form. At the same time, the disease under consideration will 
scarcely be confounded with Lepra, which has been describ- 
ed among the scaly diseases, hence it will be only necessary to 
speak of the others, whose characters, however, are so well 
marked, that a little attention will always distinguish them. 

The Elephantiasis of the Jirabs, is a wholly different af- 
fection; it does not present large tubercles, or small deformed 
tumours separated by deep fissures, existing both in the skin 
and the cellular membrane, but it consists of a uniform swell- 
ing of parts of the body, and particularly of the legs, consti- 
tuting a disease in which the skin is not implicated, at least at 
the commencement. 

Elephantiasis of the Greeks has also been mistaken for 
Syphilis, and some authors have even regarded it as a modi- 
fication of this latter affection. If it was necessary to prove 
that it was an entirely distinct disease from Syphilis* it would 



ELEPHANTIASIS. 283 

be sufficient to mention a single case, (and they are not rare,) 
where it was developed without the patient having ever had 
the slightest symptom of a venereal taint; but this opinion has 
been overturned for a long time. As regards the diagnosis, 
the tubercles of Elephantiasis may always be distinguished 
from those of Syphilis, by bearing in mind that the latter are 
smaller, hard, and copper-coloured, whilst the former are real 
tumours of a larger size, soft, &c. These syphilitic ulcerations, 
in which the edges are hard and regular, the bottom of a gray- 
ish colour, deeply excavated, and surrounded by an indurated 
cellular tissue, besides being of a circular form, are very dif- 
ferent from the smooth, superficial ulcerations of a soft and 
fungous tumour, &c. which occur in Elephantiasis. 

Prognosis.— This eruption is generally of a severe charac- 
ter, and almost always incurable. After an indefinite period, 
the patients are carried off by it: morose, unhappy, depressed, 
discouraged, and deprived of most of their faculties, a slow 
fever gradually destroys them. At other times the alterations 
of the skin extends to the mucous membranes, and the suf- 
ferer sinks from the effects of a violent chronic gastro-enteritis. 

Sometimes, however, it terminates in a more happy manner; 
the indolent tubercles become the seat of a salutary inflamma- 
tion; vitality increases in the affected parts; the small tumours 
insensibly diminish, and after some time a complete resolu- 
tion is accomplished. At other times this inflammation is more 
violent and occasions superficial ulcerations. These become 
covered with blackish, adherent crusts, which, on their disen- 
gagement, leave permanent cicatrices. Unhappily, these cases 
are rare, and are only met with when the disease is of little 
extent, when it attacks young, strong, and vigorous subjects, 
who have not been long exposed to its exciting causes, and 
finally, when it occurs for the first time. 

Treatment. — The different remedies for Elephantiasis 
are usually of little avail, from two reasons: first, the patients 
who present themselves have in most cases been affected with 
it for some years, and it is only after having fruitlessly tried 
every means, that they have left the country where they were 



284 TUBERCULAR DISEASES. 

attacked, to come to Europe in hopes of a cure: on the other 
hand, this disease in an advanced stage is often complicated 
with an irritation of the mucous membrane of the digestive 
canal, which does not permit the use of those energetic means, 
which have sometimes triumphed over this terrible disorder. 

If it can be combated at its commencement, when there are 
only spots accompanied with indolent swellings of the cellular 
tissue, the great object is to increase the energy of the parts, 
for which purpose dry frictions may be advantageously em- 
ployed, or recourse may be had to volatile liniments, or what 
is still better, the application of blisters to the diseased spots 
themselves. It was thus, in a case where the disease appear- 
ed in a young man just arrived from the West Indies, that M. 
Biett resorted to repeated blisters on the parts primarily affect- 
ed, and which eventually restored sensibility to the surfaces on 
which they were placed. 

When the disease, even in a more advanced stage, is con- 
fined to small surfaces, to the ears, for example, as we have 
sometimes seen it in the Hospital of St. Louis, resolving oint- 
ments may be advantageously made use of, as that of the hy- 
driodate of potash, in the proportion of 9i. to axunge §i. but 
above all douches of steam should be used for fifteen or twenty 
minutes at a time, on the diseased part, and during the admi- 
nistration of which the patient should constantly rub the tu- 
mours, which are sometimes of an uncommon size. If the 
eruption is more general, these douches may be replaced, 
though with less chance of success, by vapour baths. 

When it is still more extensive, in whatever state it ap- 
pears, whether the tubercles are still whole, or present scabs, 
the remedies should always be directed to the same end. 
Slightly irritating lotions, and alkaline or sulphurous baths, may 
often be useful. But we are to expect much more from a to- 
lerably active, internal treatment, if the state of the digestive 
organs does not oppose its employment. This should consist 
of the sudorifics, the tincture of cantharides, and the arsenical 
preparations. The patient may take a decoction oi guaiacum y 
rad. Chinae, and sarsopctrilla, with the addition of a small 









PRAMBffiSIA. 235 

quantity of Daphne ?nezereon or cnidium y the sudorific syrup, 
or he may be put on the use of the tincture of cantharicles. This 
preparation, which succeeds very well, especially in women, 
should be given in the dose of three, and at the end of a few 
days, of five drops, in the morning, fasting, paying strict at- 
tention to the state of the digestive and genito-urinary organs. 
This may be augmented to twenty or twenty-five drops, by 
increasing the dose by five drops every eight days. But of 
all the remedies, those which have the most direct and de- 
cided action on the skin, are the arsenical preparations, as 
Fowler's and Pearson's solution, and the Asiatic pills. The 
first is to be administered in the dose of three or four drops, 
augmenting it in the same proportion every eight days, and 
may be carried to twenty-five or thirty drops; the second, in 
the dose of a scruple to a drachm; finally, when the pills are 
used, one may be given every day, two have been used in 
some rare cases. 

But in many instances, none of these means can be em- 
ployed, as the patient, independently of the cutaneous affec- 
tion, may also be labouring under a continual irritation of the 
mucous membranes. Under such circumstances, all idea of an 
energetic treatment must be abandoned, at least for a long 
time, and the proper remedies applied to the latter diseases. 
These are diluent and mucilaginous drinks, a strict regimen, 
tepid baths, and particularly opiates. 

Whatever may be the constitution of the patient, the dura- 
tion, or state of the eruption, it is always advantageous for him 
to leave the country in which he may have been attacked. 

Frambcesia. Plan. Yaws. 

The disease which occurs in America, and has received the 
name of Pian or Epian, is the same known in Guinea by the 
denomination of Yaws; they have been described by Bate- 
man under the common head of Frambossia, which, like the 
term Yaws, corresponds to a frequent form of the disease, in 
which it resembles raspberries, or ripe mulberries. Alibert 
has also treated of it, and admitted two varieties, Pian ru- 

37 



286 TUBERCULAR DISEASES. 

boide and fungoide. The first is precisely the same as Fram- 
bcesia, and is not, as has been said by mistake in a note to 
Bateman's work, a neglected Porrigo or Sycosis of the scalp. 
As to the second, it evidently belongs to Molluscum. 

This disease is extremely rare in Europe; it appears to be 
indigenous in Africa, and is very common in the West Indies 
and America. We have had occasion, at the Hospital of St. 
Louis, to see a very remarkable case. 

Frambozsia is characterized by surfaces of greater or less 
extent, covered with tubercles, similar to small, red vegeta- 
tions, generally distinct at top, but united at bottom, and often 
presenting the form, colour, and sometimes the size of rasp- 
berries or mulberries. It may appear on all parts of the body, 
but is generally observed on the scalp, in the arm-pits, groin, 
margin of the anus, and organs of generation. Its duration is 
indeterminable, but is usually very long; it varies according 
to the state of the patient, and depends on the weakness or 
strength of the constitution. It ordinarily lasts for years. 

Symptoms. — It is seldom preceded by any general symp- 
toms, though in some cases there may be a slight uneasiness, 
and some pain in the loins; it appears in the form of small 
patches of a dull red, similar to flea-bites, and usually grouped 
around each other. Each of these spots becomes the seat of 
a protuberance, which is at first papular; the epidermis is de- 
stroyed by a slight exfoliation ; the prominences acquire more 
and more distinctness, and at last there may be perceived a 
surface, sometimes of great size, covered with vegetations, di- 
vided at their apex, but united at their base; they are of a dull 
red colour, and indolent. Sometimes, when confined to a 
small space, they resemble raspberries or mulberries; under 
other circumstances, on the contrary, they are much more ex- 
tensive, and in the case which we saw, the eruption occupied 
all the middle, anterior and inferior parts of the thigh ; the epi- 
dermis was entirely destroyed, and the disease appeared to be 
constituted, not of accidental tumours developed in the der- 
moid tissue, but by the skin itself in a state of hypertrophy, 
and divided into a multitude of vegetations. 



FRAMBCESIA. 287 

The parts in the vicinity of the eruption, are hard and cal- 
lous, the tubercles themselves are also firm and resisting, the 
inflammation is not active, and they become covered with thin, 
dry, and adherent scales. In some instances, however, the 
diseased spots inflame, the vegetations ulcerate at their sum- 
mit, and in different points of their circumference, and effuse 
a yellowish fluid, which is sometimes sanious and of a disa- 
greeable odour. This fluid spreads over the small spaces 
which separate the tubercles, soon concretes, and forms scabs 
of some thickness, which may, for a time, disguise the real 
nature of the disease. Such appears to be the most common 
course of Frambozsia. It may be supposed, however, that a 
disease so little observed, at least in Europe, may present a 
multitude of states and varieties, which, although differing 
from this description, still appertain to the disease. We have 
seen in the Hospital of St. Louis, a young girl, in whom an 
eruption, which appeared to belong to this disease, had oc- 
curred in the form of rounded, livid tubercles, the size of 
which varied from that of a pea to that of a hazelnut; they 
occupied the internal and inferior part of the thigh, and being 
united in a circular shape, formed a kind of fungous excres- 
cence, very firmly attached to the subjacent parts, and sur- 
rounded on all sides by scars which had succeeded to former 
tubercles. Some tubercles were also to be seen on the back 
and dorsal surface of the foot. Finally, in some cases, when 
the eruption has attained its greatest height, one of the tuber- 
eles may become larger than the others, even acquiring the 
circumference of half a dollar. It is much flattened, and 
changes into a large ulceration, which is bathed in an ill-con- 
ditioned fluid of so acrid a nature as to corrode the neighbour- 
ing parts. This tubercle has received in the West Indies the 
name of Mama-pian or Mother of Yaws. The disease may 
last for an indefinite time, without producing any marked de- 
rangement in the health, except in some cases, where the itch- 
ing is very violent. 

Causes. — Frambozsia appears to be contagious, but is only 
communicable by immediate contact with the matter that flows 



288 TUBERCULAR DISEASES. 

from the ulcerated tubercles. It has been supposed in the 
tropical regions, where it is so frequent, that it may be com- 
municated by insects, which, attacking both the diseased and 
healthy, may thus be a means of transmitting the disease from 
the former to the latter. It is also said that the same indivi- 
dual can only be attacked with it once in his life. It is spon- 
taneously developed. Frambcesia attacks all ages, and both 
sexes; nevertheless, it has been remarked that children are 
more subject to it than adults or old persons. Certain exter- 
nal causes, and among others, the influence of some atmosphe- 
ric phenomena, the poor nourishment of the negroes, their 
uncleanliness, the habit they have of anointing the body with 
unctuous substances, and their living in dirty, unhealthy, 
and humid cabins, appear to favour the occurrence of this 
disease. Finally, the Yaws generally attacks weak, feeble, 
scrofulous, and rickety persons. Independently of all effects 
of locality, it seems to take place more frequently among the 
blacks, and that the contagion is transmitted with difficulty to 
the whites. 

Diagnosis. — -The characters of Frambcesia are too pecu- 
liar for it to be ever confounded with any other disease. Ne- 
vertheless, it may not be useless to dwell for an instant on the 
differences that exist between it and Syphilis, especially as 
some authors have mistaken the two diseases, and even thought 
that such manifest relations existed between them, that they 
were identical. 

On the one side, if the general characters be considered, it 
will be seen that there is not the slightest resemblance. Sy- 
philis, it is true, like the Yaws, is communicable by actual 
contact, and sometimes appears in a tubercular form, but very 
different from this latter; it attacks whites equally with the 
blacks, and it never arises spontaneously. Besides, far from 
being only capable of attacking a person but once, it may ma- 
nifest itself ten, nay, twenty times, and even the tubercular 
form, the only one in which it can be mistaken for this dis- 
ease, generally accompanies a secondary Syphilis. 

On the other hand, the particular symptoms of tubercular 






PRAMBCESIA. 289 

syphilide are very different from those which characterize 
Frambozsia. It never presents red, fungous tubercles, united 
at their base, and extending over considerable surfaces, but 
is accompanied by distinct indurations, of a livid or copper- 
colour, and circumscribed extent, &c. are also attended by 
a multitude of symptoms which are peculiar to Syphilis 
alone. 

Prognosis. — Frambcesia does not appear to be immediately 
dangerous. It is less severe in whites than in blacks. Cer- 
tain forms are more obstinate than others. It usually disap- 
pears in women sooner than in men, in young persons than in 
the aged. Its duration and danger are usually in direct relation 
to the state and extent of the eruption. When it is not severe, 
nature herself sometimes effects a cure. The tubercles gradu- 
ally disappear by resolution, but in most cases, the fungous 
growths are destroyed by natural ulcerations, or caustic appli- 
cations, leaving indelible scars. Under some circumstances, 
the Yaws resists all curative means, and the disease may last 
for an indefinite time, without inducing any serious conse- 
quences. Sometimes, on the contrary, it finishes by becoming 
deep-seated, and attacking the cartilages and the bones, causing 
softening, caries, &c. and death results from the extent of the 
disorganization. 

Treatment. — Frambossia requires external treatment; at 
the same time, some internal remedies have been highly 
praised. Thus, it appears that sudorifics and purgatives have 
been used with advantage; but mercury has united the more 
suffrages in its favour, as affording the most striking results. 
Some authors, however, are of opinion that it is not only use- 
less, but that it may augment the disease, and that the cases 
where it has been successful, were syphilitic affections, which 
had been mistaken for Framboesia. 

But in most cases, the patient should be kept on a regimen 
appropriate to his situation. If he should be scrofulous, or his 
constitution be feeble and shattered, he must be put on the 
use of bitters and the tonic preparations. The arsenical re- 
medies may be employed with advantage, Fowler's and 



290 TUBERCULAR DISEASES. 

Pearson's solutions are useful in exciting energy in the skin. 
The first is to be given in the dose of three or four drops, in 
some inert vehicle, and successively augmented every eight 
days, from three to four drops, till it reaches twenty-five or 
thirty; the second is to be prescribed in the dose of from 
twelve drops to a scruple, progressively increasing it to a 
drachm. These means are sometimes very efficacious, but 
they must be intermitted if any symptoms of irritation of the 
mucous membranes should supervene. The principal reliance 
must, however, be placed on external remedies. To induce 
resolution, frictions with ointments of the proto-ioduret and 
deuto-ioduret of mercury are very useful; the first is made by 
adding 9i. to 3ss. of the salt, and the second, gr. xii. to 9i. 
to axunge §i. But more energetic means are often requisite; 
if resolution does not take place, the tubercles must be de- 
stroyed. The best caustics to employ under these circum- 
stances are the arsenical paste of Frere Come, and the acid 
nitrate of mercury. In a very severe case, in which all other 
means had failed, M. Biett had recourse to the actual cautery 
with complete success. 

The arsenical paste of Frere Come is an excellent remedy, 
and we have often seen it employed by M. Biett in other dis- 
eases, without occasioning any unpleasant consequences; but 
it is indispensable that it should only be applied to very small 
surfaces at a time, to an extent for instance, never exceeding 
that of a quarter dollar. 

The acid nitrate of mercury also acts very energetically, 
and it is necessary to use the same precautions with it. Fi- 
nally, baths, and especially those of vapour, in the form of 
douches, may advantageously aid all other remedies by excit- 
ing a healthy action in the skin. 

MOLLUSCUM. 

The name of Molluscum has been given to this disease, on 
account of the analogy of the tubercles that characterize it, 
to the nuciform prominences that occur on the bark of the 
maple. 



MOLLUSCUM. 291 

The history of this disease is very obscure, and Bateman 
was the first who called the attention of pathologists to it. It 
is the fungoid eruption of Bontius, and to this affection may 
also be referred the Pian fungoide, Al. Both before and 
since these authors Molluscum appears to have been observed 
and described under other names ; but it occurs too rarely to 
enable us to arrange its varieties. 

It is characterized by tubercles which are generally very 
numerous, and scarcely possessing any feeling, the size of 
which varies from that of a pea to that of a pigeon's egg, they 
are sometimes rounded, and sometimes on the contrary, flat- 
tened and irregular ; generally presenting a large base, but at 
times occurring with a sort of peduncle ; they may be of a 
brownish colour in some cases, but usually preserve the na- 
tural colour of the skin. 

These tubercles are developed very slowly, and follow a chro- 
nic march; they may last an indefinite time, or even during life. 
They may occur on all parts of the surface of the body, or 
even in some cases be general. Their usual seat is the face 
and neck ; Bateman has divided this disease into contagious 
and non-contagious. 

The latter consists in small indolent tumours of various 
forms and sizes, of which several are supported on a kind of 
peduncle, and is less rare than the other variety. Neverthe- 
less, there, has been much dispute as to their nature ; and this 
name has been applied to very different affections, resembling- 
each other however, by the presence of tubercles. Tilesius 
has published a very extraordinary case of this disease, in 
which it occupied the face and all the surface of the body, 
under the form of small tumours which contained an athero- 
matous matter. M. Biett has seen several analogous cases, 
but the tubercles were hard, consistent, and did not appear to 
contain any fluid. In the wards of the Hospital of St. Louis, 
we have seen, in a patient affected with Prurigo senilis, a 
multitude of small indolent tumours which existed on different 
parts of the body. The largest were about the size of hazel- 
nuts, others were about that of small peas; they appeared to 



292 TUBERCULAR DISEASES. 

be formed of a dense, fibrous substance. Pressure on them 
produced no pain. 

M. Biett has met with another form of non-contagious Mol- 
luscum, in several individuals, and especially in young females 
after delivery; it consisted in small, flat, irregular tumours, 
slightly fissured at their summit, of a brown or fawn-colour ; 
these tubercles occurred in greatest numbers on the neck. 

Contagious Molluscum is a very rare affection, and does 
not appear to have been as yet seen in France; Bateman 
himself, only saw two cases. It is characterized by round, 
prominent, hard tubercles of different sizes* these are also 
smooth, transparent and sessile, exuding a whitish fluid from 
their apex, &c. 

One of the examples cited by Bateman, occurred in a young 
w T oman, in whom the face and neck were covered with a great 
number of small tubercles ; their size varied from that of the 
head of a large pin to that of a small bean ; they were hard, 
and semi-opaque, their colour w T as nearly that of the skin, and 
their base was smaller than their body. In compressing the 
larger of these tumours, a small quantity of lactescent fluid 
could be squeezed out, through a central opening, which was 
only visible at such times. The disease had existed for a year, 
and yet but few of these tumours had augmented in size ; 
among those which had, some appeared to have a tendency to 
suppuration. Her general health was bad, and from the time 
of the appearance of the eruption, the patient had become 
much thinner. In this case, the Molluscum was developed in 
consequence of a direct communication with a child, which 
she suckled, and who had a similar tumour on the face. From 
all the information that could be obtained, it appeared that 
this child had taken the disease from a servant whose face was 
affected with it. 

The second case observed by Bateman, was in a child, who 
was seized with the disease, after having been often carried 
about by an older child who was affected with this eruption. 

Dr. Carswell, of Glasgow, has communicated a remarkable 
case of Molluscum, analogous to those given by Bateman. 



MOLLUSCUM. 



It was observed by Dr. Carswell at Edinburgh, conjointly 
with Mr. Thomson, in an infant at the breast, who appeared 
to have caught the disease from its brother, who had himself 
contracted it, in all probability, from a boy at school. One 
remarkable fact was, that after appearing on the face of this 
infant, the disease afterwards occurred on the breasts of the 
mother, and on the hands of two others of the family. The 
child died, but it was impossible to obtain permission to ex- 
amine it. In all these cases however, the disease presented 
the characters indicated by Bateman. 

Causes. — There is nothing positively known as to the causes 
of this disease. 

Diagnosis. — The form, colour, disposition and progress of 
the small tumours which constitute Molluscum, will always 
be sufficient to distinguish it from either Syphilitic tubercles, 
or from those of Frambozsia or Elephantiasis. Certainly 
the strongly marked characters which belong to contagious 
Molluscum, will afford discriminating marks between it and 
the non-contagious variety, and perhaps, if there was a certain 
number of exact observations on these two diseases, it would 
be found that there existed but little analogy between them. 
But their history is as yet too obscure for us to do other- 
wise, than to leave them as Bateman has classed them. 

Prognosis. — The prognosis of Molluscum offers nothing 
serious, when it is not contagious; the development and pro- 
gress of the tubercles do not appear to be connected with any 
internal disease; they are rarely the seat of any marked irri- 
tation, and after having arrived at a certain degree of growth, 
they remain stationary for an indefinite time, or even during 
the life of the patient, without inducing any serious conse- 
quences. Contagious Molluscum appears to be much more 
dangerous. It is usually a very obstinate disease. 

Treatment. — The treatment cannot be established in an 
exact manner from the few cases that have been observed, and 
the little knowledge we possess of this disease. M. Bietthas 
tried a multitude of remedies in non-contagious Molluscum. 
In the first variety, he has endeavoured to determine some mo- 

38 



294 



TUBERCULAR DISEASES, 



dification in the tubercles, but has never been able to produce 
the least change. As to the second form, he has been suc- 
cessful in procuring an amelioration by the aid of stimulating 
and styptic lotions. Thus, by means of lotions of a solution of 
sulphate of copper, repeated several times a day, he was able 
to remove small molluscous tumours, which occurred in a young 
female, on the whole anterior part of her neck. 

Finally, in contagious Molluscum, Bateman appears to have 
obtained good effects from the use of the arsenical preparations, 
and especially from Fowler's solution. 



( 295 ) 



ORDER VIII. 

MACULJE. 

THE skin, as we have seen, may be the seat of acute and 
chronic inflammations, which manifest themselves by a mul- 
titude of different external characters; it may also present im- 
portant alterations in its colour, which essentially differ from 
the morbid congestions that accompany, constitute, or follow 
these various inflammations. But if it belongs to cutaneous 
pathology to describe the colours which the skin sometimes 
offers, depending in all probability on some alteration of the 
pigment, we are far from thinking that it also includes all those 
changes of colour, which are dependant on another disease, 
and have nothing to do with this membrane. Hence, we shall 
avoid, in the fear of uselessly enlarging this order, noticing 
affections of such a character, (as has been done by a modern 
author,) Chlorosis and Icterus, for instance; we are too well 
aware that both these have no alliance with cutaneous dis- 
eases; that the first, a symptom of a much more serious disor- 
der, is the result of a deranged state of the circulation; that 
the other, the evident mark of an entirely different malady, 
is produced by the presence of bile in the capillaries, and does 
not even constitute a lesion confined to the skin, as other mem- 
branes offer the same colour; that neither one nor the other 
depend on a derangement or diminution in the secretion of the 
pigment. Besides, we could not treat of Icterus without be- 
ing led into discussions wholly foreign to the nature of this 
work, without we should pursue the plan of the writer above 
alluded to, and describe the symptom only, and overlook en- 
tirely the original disease; but it appears to us that it would 
be as erroneous to give a history of Icterus, without that of 
the lesions of the digestive organs of which it is the result, as 



296 MACULiE, 

to describe as a disease of the skin, the loss of feeling of this 
membrane, separate from an account of the alterations of the 
nervous system which may produce it. 

We shall therefore only include in this order the alterations 
of colour, which themselves depend on some change in the 
pigment. 

The diseases arranged in this order are characterized by dis- 
colorations or decolorations of the skin, which appear in the 
form of spots of various sizes, and differ in a more or less 
striking manner from the colour of the surrounding parts, or 
at least from the usual hue of the skin. 

Macule are general or partial; when they are partial, they 
may, it is true, occupy almost all the skin, but then there is not 
a continuous patch as when they are general; they consist of 
spots of various sizes, leaving intervals between them, where 
the natural colour remains uninjured: sometimes they occur on 
one region only, as is often seen in Lentigo of the face. At 
other times, again, there may be but one single spot of small size, 
as in Nsevus. The duration of these affections varies according 
to the species: that of congenital discolorations and decolora- 
tions, of general Maculas, of some of those which are partial, 
is generally indefinite; it is only in the Ephelides, properly 
speaking, that we are able to assign a term of their continu- 
ance, this generally varies from one to three months. 

These Maculae appear to be seated in that layer of the mu- 
cous tissue which is charged with colouring matter, (Gem- 
mules, Gaultier,) and they evidently depend on an alteration 
of the pigment. It is, therefore, highly important to distin- 
guish them from those hues which are produced under the in- 
fluence of the vascular system, and which may depend on a 
congestion of the capillaries, or even on a want of action in 
these vessels, and in other cases again on the presence of fo- 
reign bodies in the circulatory system. But, notwithstanding 
the labours of skilful anatomists, notwithstanding the learned 
reseaches of Gaultier, the anatomy of the skin is still far from 
being perfectly known; although the nature and formation of 
the pigment are not the least obscure points, and whilst wait- 



MACULJE. 297 

ing for more positive information, it is reasonable to suppose 
that there must be a great difference in the nature and seat of 
Ephelis and Icterus, of Vitiligo and Chlorosis. 

Causes. — The cause of the generality of Maculae, is still 
entirely unknown ; thus it has been often remarked, that the 
internal administration of the nitrate of silver, will sometimes 
produce a general dark hue of the skin; but as yet, the labour 
of chemists, the observations of physicians, and the researches 
of anatomists, have not been able to explain this singular phe- 
nomenon. 

We have no guide to explain the reason of Nsevi materni, 
beyond the vulgar belief which attributes them to moral im- 
pressions sensibly felt by the mother. We can scarcely be- 
lieve, in the generality of cases, in these effects of an excited 
imagination, effects that are often attributed to a transient 
cause, and to which so little attention was paid at the time of 
its occurrence, as to be with difficulty recollected. Neverthe- 
less, there are cases so well authenticated, and there is often 
such an exact resemblance between the objects which have ex- 
cited the feelings of the mother during gestation, and the marks 
on the body of the child, that, in spite of ourselves, we are 
tempted to believe that a certain influence may, under some 
circumstances, be exercised on the foetus, through impressions 
received by the mother. 

Ephelis is generally developed under the influence of causes 
which are to a certain degree appreciable. 

Diagnosis. — Maculse present characters of sufficient dis- 
tinctness, to be in most cases distinguished from other dis- 
eases of the skin. The symptoms of each of the varieties will 
always prevent their being mistaken for each other. Never- 
theless, there are some discolorations which may be confound- 
ed with syphilitic spots, but as these latter can only be taken 
for Ephelis, we shall point out in the diagnosis of that disease 
the differences that exist between them. 

Prognosis and Treatment. — Although the Maculse are for 
the most part incurable, they are seldom serious, and exercise 
little influence on the general system. Ephelis appears to be 



293 maculje. 

the only one which is susceptible of being cured; it is far from 
obstinate, and usually yields to very simple means. As to the 
other varieties, the obscurity which still exists as to their na- 
ture, will explain the little success that has attended any attempts 
to combat them. The order of Maculae corresponds tothe Ephe- 
lides, Al. who has divided it into Ephelide lentiforme, (Len- 
tigo,) Ephelide hepatique, (Ephelis,) and Ephelide scor- 
butique; this latter variety cannot be referred to the Maculae, 
but rather belongs to Purpura, which constitutes a very dis- 
tinct affection. 

Under the common head of Ephelides, Alibert only de- 
scribes one species of discoloration. 

We shall divide the Maculae into discolorations and deco- 
lorations. 

Discolor ations. 

Independently of the changes of colour, that we have said 
above, depend on the capillary circulation, and do not belong 
to diseases of the skin; this membrane presents a multitude of 
different tints, which succeed to diseases, of which it is the 
seat, or which accompany them, the study of which is of the 
highest importance; thus the spots which succeed Pemphigus, 
the fawn colour of Elephantiasis grascorum, the peculiar 
hue that accompanies the syphilitic eruptions, &c. assuredly 
present differences which cannot escape an attentive observer, 
but are actually impossible to describe. Some day, no doubt, 
when the intimate structure of the skin is better known, these 
different appearances will be satisfactorily accounted for. 

Those discolorations of the skin, which are really idiopa- 
thic diseases of this membrane, are either general or partial ; 
the bronze colour is the only one that is general; to the par- 
tial discolorations, belong Lentigo, Ephelis, and Naevus. 



DISCOLORATIONS, 299 



Bronze colour of the Skin. 

There are many instances of individuals in whom the skin has 
more or less promptly assumed the bronze hue. This morbid dis- 
coloration is particularly observable after the internal use of ni- 
trate of silver; but it has alsobeenseen in persons whohad never 
made use of this remedy, and we have ourselves twice met 
with it in patients, in whom it had arisen spontaneously under 
the influence of some unknown cause. M. Biett has also ob- 
served several instances of it. In these cases, the discolora- 
tion is much less deep than when it is the result of the inges- 
tion of nitrate of silver ; the skin seems rather to present a 
dirty appearance than a bronze tint. 

It is, on the contrary, very dark, when it succeeds to the 
administration of this salt, where it has been employed for 
some years as a remedy in Epilepsy. Sometimes followed 
by a complete cure, or at least, by a manifest amelioration, 
the use of this substance occasions in many cases a slate-gray 
colour of the skin, which, in the light, appears of a greenish 
tint, and differs entirely from the colour of mulattoes, to which 
it has been erroneously compared. M. Biett has employed it. 
with success in many epileptic patients, and in some, its use 
was followed by this discoloration of the skin. Among them, 
three came under our notice. In two of these, the fits were so 
constant that they menaced the existence of the patients, and they 
were so much relieved that they only had them every three or 
four months, and then very light ; in the other, the disease was 
entirely cured, and no symptom of return has been experienced 
for more than ten years. The nitrate of silver left a dark co- 
lour of the skin, but did not injure the health of the patients 
in the slightest degree \ the case of one of whom has been re- 
ported erroneously, and embellished with imaginary incidents, 
in a work recently published, 

C— — was, in fact, admitted into the Hospital of St. Louis, 
for an Epilepsy^ the attacks of which were so frequent, that 
they endangered his life. He was put on the use of the nitrate 



300 MACULJE. 

of silver, which he continued for fifteen months, and not for 
three years, as has been said. This remedy, which was inter- 
mitted from time to time, was given in the dose of half a grain at 
first, and progressively augmented to eight grains daily. Its ad- 
ministration never occasioned the slightest ill consequence, and 
it is erroneous, that it caused a gastro-enteritis, which lasted 
for a year, and from which the patient has not yet perfectly 

recovered. The fact is, that C has never experienced 

any symptom of gastro-intestinal inflammation, that the state 
of meagreness in which he now is, existed before his entrance 
into the hospital, that his digestive functions are very active, 
and are in a normal state. The nitrate of silver, therefore, 
has had the effect in this person of relieving him so much, that 
the fits only return at intervals of some months; that they are 
extremely light, and do not occasion a loss of his senses, and 
has been followed by no other inconvenience than the dark 
colour it has occasioned in his skin. 

This appearance usually manifests itself some time after the 
employment of the nitrate of silver has been commenced; the 
skin at first assumes a bluish tint, and gradually becomes slight- 
ly bronze-coloured; this is the more evident where the colour- 
ed parts are exposed to the light. It appears on all parts 
of the surface of the body at the same time, but is generally 
most sensible where the skin is delicate; and particularly in 
those exposed to the action of the light, as the face and hands. 
The discoloration gradually assumes a darker tint, till it may, 
in some instances, become almost black. It should be remark- 
ed that the conjunctiva usually presents a coppery, livid hue, 
that the mucous membrane of the mouth, at the points of 
junction with the skin, where it is exposed to the light, is the 
seat of an analogous discoloration. 

A very remarkable phenomenon is, that in the face this 
bronze colour becomes darker, from all the causes which usu 
ally produce paleness; it is, on the contrary, lighter where 
redness would naturally take place. 

It may last a considerable time, or even preserve its inten- 
sity during life. M. Biett has seen two persons in Geneva, 



DISCOLORATIONS. 301 

in whom this discoloration had existed for more than twenty- 
years, and for the fourteen years in which he has used the ni- 
trate of silver in Ejrilepsy, he has observed a number of indi- 
viduals in whom this colour has remained as dark as when it 
first appeared. There are some cases, however, in which the 
discoloration has progressively diminished, but there is as yet 
no example of its entirely disappearing. 

It is never accompanied with any general symptoms, or de- 
rangement in the functions ; and even those parts which are 
connected with the skin, experience no alteration. Thus, the 
hair remains uninjured, though the nails are usually of a bluish 
tint. In most cases, cicatrices which existed before this change 
took place, are also implicated; sometimes, however, they do 
not participate in it; those that occur afterwards, M. Biett has 
observed, remain white, especially if they were somewhat 
deep. 

This discoloration, the cause of which was for some time mis- 
understood and denied, has been observed by a host of practi- 
tioners, who have had occasion to employ the nitrate of silver 
in Epilepsy, &c. Without speaking of Fourcroy, who was 
the first to draw attention to this important fact in physiolo- 
gical pathology, there may be cited Powell, Marcet, and Ro- 
get, in England; Albers, Reimar, Schleiden, in Germany; 
Butini, Delarive, and Odier, in Switzerland; Biett, who has 
himself observed it in twenty -three cases, (seven women, and 
fifteen men,) without including those he met with in England 
and Switzerland. The greater part of these individuals have 
been observed several years after the first appearance of the 
discoloration, and in the generality of them it had not in the 
least faded. 

What influence has the nitrate of silver on the secretion of the 
pigment? Are these effects to be attributed to a chemical com- 
bination, in which light appears to exert great influence ? In 
the actual state of our knowledge, this phenomenon is not sus- 
ceptible of a clear explanation ; all the hypotheses which have 
been made, may be met with strong objections. The most, 
part of the questions that Albers, of Bremen, addressed to 



302 MACULiE. 

the Medico-Chirurgical Society of London, on this subject, 
are yet to be answered. 

This discoloration is not dangerous; in fact, it can scarcely 
be called a real disease. 

We possess no means which are capable of destroying this 
morbid colour, and of restoring the skin to its natural state. 
So far, the trials that have been made to attempt to modify it 
have failed ; M. Biett prescribed to two of his patients, who 
have been under his care for near fourteen years, sea-bathing, 
alkaline and ferruginous baths, but without obtaining the least 
change. Dr. Badely is mistaken, in asserting that blisters 
will restore the skin to its natural colour. M. Biett, whom 
we are again obliged to cite on this point, applied them to the 
hands of one of his patients, but the skin still retained its 
morbid hue. Nevertheless, it is probable, that reiterated ap- 
plications, taking care to often wash the denuded parts, might 
considerably diminish the intensity of the tint, as cicatrices 
produced by excoriations have been known to regain the na- 
tural colour. At the same time it must be remarked, that in 
making these repeated applications of blisters, at least on the 
face, (where it is most striking,) almost insurmountable ob- 
stacles will be met with in the eyelids, conjunctiva, &c. An 
individual, thus partially discoloured would present a kind of 
chequered appearance, more disagreeable than an uniform 
colour, however unnatural. This reason has hitherto pre- 
vented M. Biett from pushing the plan any further. 

Lentigo. Taches de rousseur. Ephelide lentiforme, AI. 

Lentigo, which is generally known under the name of 
Freckles, is characterized by small spots, usually of a yellow- 
ish fawn-colour, rarely exceeding a small bean in size, and 
generally much smaller. These are in most cases conge- 
nital, but in some instances are developed after the age of 
nine or ten, and last the whole life, though they are more 
evident at certain times. Thus they are very numerous, and 
more strongly marked in youth ; they generally occupy the 



!' 



DISCOLORATIONS. 303 

hands, the neck, the upper part of the hreast, and above all, 
the face. Hence it is evident, they affect those parts which 
are exposed to the light; they may, however, cover almost all 
the surface of the body, and we have seen individuals, the 
whole of whose skin was thus spotted. 

Symptoms. — They appear in the form of small spots of a 
yellowish colour and nearly round, scattered here and there 
without any order, and leaving intervals of different extent 
between them, in which the skin preserves its natural colour. 
Sometimes they unite, particularly on the nose and cheeks, 
and form large patches. They are not in the least prominent, 
occasion no pain, not even itching, and are rather a blemish 
than a disease. 

Causes. — Lentigo is only observable in persons of a fair 
complexion or those with red hair, in whom the skin is fine, 
white and delicate ; it is very seldom seen in brunettes. It 
is sometimes occasioned by exposure to the sun. Thus it is 
not rare to meet with small yellow spots, &c. in persons living 
in the country, particularly in children, and those who expose 
themselves to the action of the sun; in these cases it is acci- 
dental, and may disappear by age or change of climate. It is 
most common in warm countries, and is often met with in 
persons of a lymphatic temperament; it is seldom seen in the 
dark-complexioned, or in those who are strong, vigorous and 
sanguine. It is usually congenital. 

Diagnosis. — The characters assigned to Lentigo are too 
well marked, and it is a disease too well known for any mis- 
take to occur. Nevertheless, when situated on the body, it 
may in certain cases, be taken for a variety of Purpura. In 
fact, this latter disease sometimes manifests itself by small 
round patches, not larger than a bean, and oftentimes much, 
less; but the spots of this disease are of a livid red, whilst 
they are yellowish in Lentigo; the first may occur on the 
body and limbs without showing themselves on the face, which 
is very seldom their seat; the latter, on the contrary, scarcely 
ever exist on the breast or abdomen, without at the same time 
affecting the face and neck. Finally, the spots of Purpura 



304 MACULE 

are accidental, and in these cases, generally very transient; 
they almost always coincide with some derangement of the 
system, whilst those of Lentigo, are ordinarily congenital, 
last during the whole life, and are never accompanied by the 
slightest disturbance of the functions. When several of the 
spots are united, they may be confounded with Ephelis, but 
the presence of small isolated Maculae, their duration, and the 
absence of itching, are characters which are more than suffi- 
cient to distinguish them. 

Lentigo sometimes disappears, but it most generally is 
persistent; it never constitutes a disease, properly speaking, 
and requires no treatment. 

Ephelis. Pityriasis versicolor. Taches hepatiques. Ephe- 
lides hepatiques, Al. 

Ephelis is characterized by irregular patches of a much larger 
size than those of Lentigo, of a saffron-yellow colour, usually 
accompanied with itching, and sometimes giving rise to a 
slight exfoliation. These eruptions may appear on all parts 
of the surface of the body; but they are generally met with 
on the anterior part of the neck, the breast, on the breasts in 
women, on the abdomen, groins, and internal parts of the thighs. 
They are never seen on the face, except in pregnant women, 
when they are evidently dependant on this state. Their duration 
varies from some days to two months or more. Often arising 
in a sudden and spontaneous manner, they rapidly disappear; 
in other cases they may be developed a short time before the 
menstrual period, and vanish when this evacuation makes its 
appearance. But in most instances they appear gradually, 
and in a slow manner, and last several weeks, and if no 
remedies are applied, may remain for months. 

Symptoms. — Preceded by a slight itching, these eruptions 
manifest themselves by small round spots, which are at first 
of a grayish colour, but afterwards acquire a yellow tint, 
which sometimes is as vivid as that of saffron. But their colour 
varies greatly, according to the individuals or the part that 
may be affected. They at first offer different diameters ; some 



DISCOLORATIONS, 305 

being of the size of a dime, others much smaller, whilst some 
again may greatly exceed this. They are at first isolated, 
distinct, and scattered here and there, leaving large intervals 
between them, in which the skin preserves its natural colour; 
but they soon multiply, enlarge, unite and form large irregular 
patches, which sometimes occupy surfaces of such an extent, 
that on a superficial examination, we might be tempted to con- 
sider the unaffected spots the diseased part, and the disease 
the natural colour of the skin. They are not prominent, 
and are not elevated above the surrounding skin ; neverthe- 
less, in passing the finger over the surface, a slight prominence 
may be felt, which depends in all probability, on the furfura- 
ceous desquamation which they often occasion. 

These eruptions are not accompanied with any general 
symptoms, and give rise to no derangement of the functions, but 
they always determine troublesome itching. The pruritus is 
considerably augmented by any mental excitement, and espe- 
cially by any excess. It is usually most violent in women 
and girls about their menstrual periods. It sometimes becomes 
so violent that patients cannot resist the propensity to scratch 
themselves, which, far from calming it, only increases the evil. 
This itching is often increased by the heat of the bed, and 
sometimes occasions long and painful vigils. 

Sometimes Ephelis is accidental and transient, terminates 
by resolution, and disappears in a few days, and in some cases, 
even in a few hours; in other circumstances, it gives rise to an 
epidermic exfoliation, and follows a slow march, remaining 
for a long time. 

Causes. — These eruptions may appear on all persons; they 
attack both sexes indifferently, but they are more often met 
with in females, and principally in those who are fair and have 
a fine and delicate skin, although it is not rare to find them in 
those of an entirely opposite appearance, having black hair, 
and a dark complexion; in these cases, the spots are much 
darker coloured. They are sometimes occasioned by exposure 
to the action of the sun, by excesses, by the ingestion of cer- 
tain salted or smoked meats, &c; they often coincide with a 



306 MACUL2E. 

suppression or diminution of an habitual discharge, as the 
menstrual or hemorrhoidal; in some females, they appear to 
depend on the latter cause, and soon disappear. These spots 
have been met with in persons who were at the same time 
affected with a chronic inflammation of the liver, and their 
origin has been attributed to this organ, fEphelides htpa- 
tiques. ) This complication, which only occurs in some rare 
cases, is far from constituting a disease always dependant 
on the same cause. The hepatic Ephelis is not more under 
the dominion of the liver, than it is under that of the sto- 
mach or lungs. In the generality of cases, persons who 
are affected with it, enjoy very good health, and the dfa 
wholly consists of an alteration of the pigment of the skin. 
The spots so often occurring on the face of pregnant women, 
belong to this eruption. 

Diagnosis. — The characters assigned to Ephelis are too 
well marked in the generality of cases to render their diagno- 
sis difficult There are, however, some diseases of the skin, 
which may, under certain circumstances, be mistaken for them; 
these are Pityriasis, Syphilitic spots, and Xtri. 

Pityriasis. — This is a scaly disease, and the spots under 
consideration are not merely followed by a slight farinaceous 
exfoliation, but by a desquamation formed of the disengagement 
Of small lamellae of altered epidermis. The absence of the 
yellow tint which characterizes Ephelis, will suffice to dis- 
tinguish it from Pityriasis, although at the first glance, it may 
appear to resemble the latter from its exfoliation, ami the 
slight degree of prominence. 

Pityriasis is never accompanied with the pruritus, which 
is so common in Ephelis. 

Syphilitic spots. — The livid or coppery colour, the want 
o( exfoliation, the absence o( all itching, of concomitant symp- 
toms. &c will always distinguish those discolorations which 
arise from a venereal cause. 

\;rri. — Some X:vn\ when their colour is of different shades 
of yellow, somewhat approaching that oi Epheiis, and which, 
at the same time. i\o not rise aboye the level of the ^kin. may 



DISCOLORATIONS. 307 

sometimes be confounded with the disease under consideration ; 
but it may easily be conceived, that independently of their 
small number, sometimes indeed their unity, the absence of all 
itching, their congenital origin and incurability, are characters 
which will soon dispel any error, and clear up every doubt. 

Prognosis. — Ephelis constitutes a very mild disease; those 
which appear in the first period of pregnancy, sometimes dis- 
appear during the first months; at other times, they last until 
delivery has taken place, but they ought not to occasion any 
uneasiness, and do not require any kind of treatment. Those 
which precede or accompany the menstrual periods, are ex- 
tremely transient. Under other circumstances, they are attend- 
ed with no other inconvenience than the itching, which, how- 
ever, in a majority of cases, will yield to an appropriate 
treatment. 

Treatment. — Astringent lotions, detersive liniments, alka- 
line ointments, and all those resolving applications which are 
efficient in giving tone to the skin, are at least useless, and 
may even be hurtful. The treatment of Ephelis is extremely 
simple. Sulphurous waters internally, as those of Enghien or 
Cauteretz, two or three sulphurous baths a week, and in cer- 
tain cases, some mild laxatives are all that are necessary in 
most cases. In commencing the use of the Enghien water, 
the patient should at first mix it with two-thirds of barley 
water or milk, and gradually augment its strength till he can 
take it pure. 

In some instances, where Ephelis occupies certain regions, 
as the internal part of the thighs or groin, and occasions a vio- 
lent pruritus, the patient should wash these parts with a lotion 
made by dissolving one ounce of sulphuret of potash in two 
pints of water, on the days when he does not take a bath. It is 
scarcely necessary to add, that the patient should avoid all ex- 
cess, and particularly refrain from spirituous liquors. 



308 MACULJE. 



Nssvi Mater ni. 

Under the denomination of Nsevi materni, are included all 
those congenital marks on the skin, which are vulgarly attri- 
buted to impressions made on the mother, and transmitted to 
the foetus. These different affections have been designated 
under the names of Spili, of £***•*, Macula, of Nsevi, pro- 
perly speaking, and of Moles. Thus, on the various parts of 
the body, coloured spots and marks are often to be seen of re- 
markable forms, &c. 

1st. Sometimes these marks do not rise above the level of 
the skin, ( Spili,) and evidently consist in an alteration of 
the pigment; they may appear on different parts of the surface, 
without any reason being assignable why they occur in such 
or such a situation. They are, however, most frequent on 
the face. They are congenital, and may diminish in depth of 
colour, but they never disappear entirely, and last a lifetime. 
They present a multitude of shades of colour, of form, and 
size, which it would be impossible to describe. There are few 
tints that these Nsevi have not assumed, but they are most 
commonly yellowish, or entirely black; in these latter cases 
especially, they become covered with harsh and short hair. 
Their form is generally irregular; sometimes, however, they 
strongly resemble that of certain objects, which has been one 
great cause of the belief of their being caused by some impres- 
sion made on the mother. Sometimes they are confined to 
very small spaces; but on the contrary, under some circum 
stances, they may occupy very extensive surfaces ; half the 
face for example, the whole of a limb, a great part of the body. 
These coloured spots do not occasion any pain, and are unac- 
companied with itching. Sometimes their hue diminishes 
little; at other times it remains the same, and lasts for life. 

2d. Sometimes these marks on the skin, (Nsevi,) are no 
merely an alteration of the pigment, but are connected with 
and under the influence of the vascular system, and may pre 
sent two different states. 



DISCOLORATIONS. 309 

In one, they are entirely superficial, and constitute spots 
whose tint is entirely under the influence of all causes which 
quicken the circulation. Usually of a red or violet colour, (wine- 
marks,) they are augmented in intensity by excesses, by a strong 
mental impression, at the approach of the menstrual period, &c. ; 
the skin, in some instances, may even appear tumefied. In 
the other, they are more or less prominent, rounded, flattened, 
or raised on a footstalk; they constitute almost the whole of the 
erectile tumours of Professor Dupuytren. We shall confine 
ourselves merely to the mention of these vascular Nasvi, from 
their being connected in a certain degree with the Maculae, 
but their history and modes of cure belong to surgery. 

3d. Finally, by the term Moles, are meant small, brown 
spots, sometimes superficial ; in other cases, on the contrary, 
slightly prominent, generally of a round form, scarcely ex- 
ceeding a small bean in size, and in which hairs are always to be 
seen. Moles sometimes belong to the spots, sometimes to the 
vascular Nxvi. They generally, however, appertain to this 
latter variety ; for they may occasion itching, swell, and be- 
come painful from the effect of some irritating cause. They 
are most commonly developed on the foetus, but they have 
been seen to arise after birth, in which case they are suscepti- 
ble of augmenting and disappearing. 

We are entirely ignorant of what may be the proximate 
cause of Neevi, and in allowing, according to the common be- 
lief, some influence to emotions of the mother, effects which 
are evidently wanting in the majority of cases, but which can- 
not be entirely overlooked in all instances, there still remains 
great obscurity as to their mode of formation. It has been 
said that Naevi were most frequent in those infants whose mo- 
thers were subject to inflammations of the skin. This observa- 
tion, if it was rigorously true, which has not been demonstrat- 
ed, would still be but a simple fact, and would not throw any 
light on the etiology of these cutaneous alterations. 

Nasvi do not, in general, require any kind of treatment; 
they must be left to themselves — at least those which depend 
on an alteration of the pigment, ( Spilt. J They can only be 

40 



310 MACUL2E. 

destroyed by caustics or the knife; but these operations, 
which would only be undertaken to remove disagreeable spots, 
since they can scarcely be termed a disease, are useless, from 
their leaving scars quite as unsightly and deformed as the spots 
themselves. 

As to the vascular Nasvi, and particularly those which con- 
stitute tumours of greater or less prominence; their seat, and 
the danger resulting from any injury to them, by exposing the 
patient to a violent haemorrhage, are sometimes such as to 
render it indispensable that they should be removed; their 
treatment, however, belongs to surgery. It consists in com- 
pression of the tumour, in removing it by means of ligatures 
or the knife, and finally, in tying the arterial trunk, from 
whence it derives its blood. Cauterizations have appeared to 
have been attended with serious consequences.* 

Decolorations. 

Not only may the skin present changes in its usual colour, 
depending on an alteration of its pigment, but it may also in 
some instances, be entirely deprived of this substance; this 
decoloration may be congenital or accidental, partial or ge- 
neral. 

•Albinism. 

General and congenital decoloration constitutes that singu- 
lar state, known under the name of ^Albinism., which is the 

* Vaccination has been successfully employed in removing these obsti- 
nate, and oftentimes unsightly tumours. Dr. Young, in the Glasgow Medi- 
cal Journal, gives the result of two cases in which this was tried, and observes 
that if early attended to, after the birth of the child, that nothing further is 
required to effect a cure, than to establish the process of suppuration by cow- 
pox, caustic, &c. As the most gentle of these means, the vaccine is cer- 
tainly entitled to a preference. He also seems to think that an antimonial 
plaster would be a good substitute, if vaccination had been previously per- 
formed, without the nxvus having been adverted to. This hint deserves 
attention. — Thans. 



DECOLORATIONS. 311 

more remarkable, as the Albinos do not form a distinct race, 
but are observed throughout the whole human species. 

The skin of persons thus uncoloured, is of a dead white, 
somewhat resembling that of milk ; their hair is smooth and 
silky, often feeling like that of the goat, and is sometimes of 
a brilliant wmite ; the eyebrows, eyelashes, beard, the hair 
in the arm-pits, and around the genital parts, are of the same 
colour; all the rest of the body is covered with a silky down, 
of a snow-white colour, and remarkable softness. The iris is 
rose-coloured, and the pupils present a well-marked, red tint; 
changes which depend on the absence of the pigmentum ni- 
grum from the choroid and uvea. The eyes cannot support a 
brilliant light; its impression always appears to be painful. 
Thus, when they are exposed to a glare, they are continually 
winking, and the pupil has a rapid oscillatory movement. On 
the contrary, towards night, and when the day is dark and ob- 
scure, the Albinos can distinguish objects with great ease. 
The physical and moral development of Albinos, like the de- 
coloration of their skin, is indicative of general feebleness of 
organization. They are usually small, delicate, and feeble. 
Their intellectual faculties are ordinarily obtuse, and it is not 
rare to find Albinism accompanied with idiocy. We do not 
know of any example of accidental general decoloration. 

These decolorations appear, as we have said, to depend on 
the absence of pigment; as to the primary cause, it is wholly 
unknown. Albinism does not appear more dependant on cer- 
tain races, than on climate; it affects both blacks and whites, 
and is met with as well in Europe as in Africa, although it is 
certainly more common in some countries than in others. 

Albinism presents such marked characters, that it is impos- 
sible to mistake it; it is a state which is visible at the first 
glance, and is, as may well be supposed, beyond all resources 
of art, and never requires any medical treatment. 



312 MACULiE. 

Vitiligo. 

The skin may also become the seat of partial decolorations, 
and this disease, known under the name of Vitiligo, may be 
congenital or accidental. The first is only met with in ne- 
groes, who sometimes present white spots, of various forms 
and dimensions, on different parts of their body. When these 
spots occur on those parts which are covered by hair, this also 
becomes deprived of colour. Those negroes who exhibit this 
peculiarity, are termed piebald. 

But Vitiligo is most usually accidental, and this is the only 
form observable in whites; it may occur on all parts of the 
body, but is usually met with on the scrotum in men: it ap- 
pears in the form of milk-white spots, which are very irregu- 
lar in their shape, being sometimes in longitudinal striae. In 
other cases, on the contrary, it manifests itself in superficial 
patches, which are unaccompanied by either heat or itching. 
These spots, which occur most frequently in the aged, may 
gradually increase in size, till they cover a considerable surface. 

Causes. — Vitiligo is developed under the influence of 
causes which have not as yet been discovered. 

Diagnosis. — It presents itself with such peculiar characters 
that it can never be mistaken. But, at the same time, care 
should be used, not to confound it with the white lines observa- 
ble on the skin of the breasts, when they are over-distended 
with milk during suckling, or with those which take place on 
the abdomen, from ascites or during pregnancy; these white 
lines, to which the name of Vitiligo has also been applied, 
( Vitiligo hydropicorum, gravidarum, J. Franck,) are not 
mere decolorations, but result from the destruction of the rete 
mucosum, caused by rents or tears from the over-distention. 

Treatment. — We have seen several examples of Vitiligo, 
at the Hospital of St. Louis; but it rarely occurred that the 
patients had entered the wards for this affection. Those who 
were treated for it, received no benefit from the usual means 
employed for such diseases; in fact, we do not know a single 
case in which any change took place, and would not advise 
that a cure should be attempted. It is a very slight affection, 
and is attended with no disturbance of the system. 



( 313 ) 



Diseases which from their Nature cannot be arranged in 
any of the Foregoing Orders. 

ORDER IX. 

Lupus. Dartre rongeante. Lupus vorax. Herpes exedens. 

THIS disease has been described under the name of Dartre 
rongeante^ by Alibert, who has divided it into three varieties, 
based on the causes which produce them: 1st. Dartre ronge- 
ante idiopathique; 2d. Dartre rongeante scrophuleuse; 3d. 
Dartre rongeante venirienne; this last evidently belongs to 
the syphilitic complaints, and the author himself describes it 
under that head. 

Lupus is a disease which sometimes commences with spots 
of a violet red colour, but most generally with livid, indolent 
tubercles, and is above all characterized by its tendency to 
destroy the surrounding parts and subjacent tissues, under the 
form of ill-conditioned, ichorous ulcers, which become covered 
with very adherent brownish scales, which on falling off dis- 
cover that the disease has continued its ravages. 

Lupus presents many differences, not only in its seat, the 
rapidity of its progress, and the extent of the destruction it 
produces, but also in the mode in which these ravages are 
committed, and in the form of the ulceration. Thus, some- 
times it confines its attacks to the surface, sometimes it suc- 
cessively invades the subjacent parts, at others, again, it is ac- 
companied with a real hypertrophy of the skin; hence M. 
Biett has divided it into three varieties: 1st. That which de- 
stroys the surface; 2d. That which destroys the subjacent 
parts; 3d. When it is accompanied with hypertrophy. This 
division is wholly practical, and much facilitates the study and 
description of the disease. 

The most general seat of Lupus is on the face, and the nose 
is the point on which it ordinarily exercises its ravages, we 
are not, however, able to explain this singular predilection: 



314 LUPUS. 

the cheeks, lips, and chin are also favourite spots of attack, 
but it may also occur on the body and limbs. On the body 
it is usually to be found on the breast or shoulders; on the 
limbs its seat is generally around the articulations, on the ex- 
ternal part of the forearm, back of the hand, and on the foot. 
Finally, it is not uncommon to see this disease on the' neck. 
In certain cases, it is confined to one point, in others it at- 
tacks, simultaneously or progressively, several regions. 

It usually commences with an obscure red point, which is 
hard, prominent, and seldom of any great size. These small, 
indolent swellings, whose progress is slow and gradual, have 
been considered as tubercles. They may remain stationary, 
or nearly so, for a long time; sometimes, on the contrary, 
their volume is very considerable from the first; in all cases 
they are of an obscure red colour, and appear at the commence- 
ment only to affect the most superficial layers of the skin. 
Their summit sometimes becomes covered with small, dry, 
white scales; in many cases, several may unite and form a large 
diseased surface, which, however, is not painful, it is soft, 
and finally ulcerates. 

Although this is the most common appearance of Lupus, 
it does not always occur with these characters, and hence it is 
erroneous to class it with the tubercular inflammations, for it 
very often happens that tubercles are not the primary lesions 
of Lupus. Thus it sometimes begins by an inflammation of 
the mucous membrane of the nasal fossae, accompanied with 
swelling and redness of the nose; a thin scab is formed, this 
is torn off, it is replaced by another, and the ravages of the dis- 
ease commence. In some instances, it manifests itself by a 
violet redness on some part of the face, but especially at the 
extremity of the nose, which, at the same time, is the seat of 
a slight swelling lasting for some months, the colour slowly 
augments, the surface becomes inflamed, a slight ulceration oc- 
curs, and a scab is formed, which soon becomes thick, and 
covers an ulcer which is gradually becoming deeper. Finally, 
the skin may slowly become thin, and present the appearance 
of a scar without having been preceded by tubercles or ulce- 



lupus, 315 

rations, and without having offered any other lesion than that 
of a livid hue, accompanied from time to time by a slight des- 
quamation, so slight, indeed, as in some cases to be scarcely 
appreciable. 

Lupus destroying the surface. — Lupus, when spread over 
an extent of surface, offers some peculiarities, which merit at- 
tention. Thus, in some rare cases, the disease appears to 
affect but the most superficial layers of the dermoid tissue. 
This variety is especially observable on the face and cheeks; 
it does not commence with tubercles, nor does it form scabs, 
but the skin assumes a red colour; epidermic exfoliations take 
place on the diseased surface; the skin gradually becomes thin; 
it is smooth, shining, red, and presents the appearance of a ci- 
catrix left from a superficial burn ; the redness disappears on 
pressure; the patient experiences no pain, except on the dis- 
eased spot being touched. The surface becomes sensible af- 
ter violent exercise or excess in drinking. When the disease 
ceases to make any further progress, the redness disappears, 
the exfoliation no longer takes place, but the skin remains thin 
and shining, it is smooth to the touch, and appears deficient 
in thickness. 

In other cases one or more small tubercles of a dull red colour 
appear; after remaining stationary for some time, they sud- 
denly increase and multiply, the skin becomes the seat of 
a slight oedematous swelling in the intervals which separate 
them; their bases join, the summit ulcerates, and in a short 
time there is a continuous surface, presenting an irregular, ill- 
conditioned ulceration. This is soon covered with a very 
adherent blackish scab, and gradually extends. In most cases 
when the disease thus has a tendency to extend to the sur- 
rounding parts, white, wrinkled, irregular scars, somewhat 
resembling those which result from large burns, are formed 
on the original points of attack. This phenomenon especially 
takes place during a well-directed curative course. Lupus 
may gradually spread over large surfaces; all the face for in- 
stance; it may often occur with even greater violence, and 
whilst it successively extends to the surrounding parts, the 



316 lupus. 

former cicatrices also become involved in the ulceration. In 
fact as they always are closely united at some point with red 
prominent tubercles, which seem to serve as a point of attach- 
ment to them, the ulceration which occurs in these tubercles 
soon extends to the cicatrices and destroys them. It is always 
by the formation of fresh tubercles, which circumscribe the 
ravages of Lupus for a time, by a kind of hard, rough, 
swelled ridge, which afterwards ulcerate, that this disease ex- 
tends. We have seen in the Hospital of St. Louis, a Lupus 
of this kind commence on the sub-maxillary region, gradually 
extend, and in spite of all treatment, in the course of a few 
years involve all the chin, a great part of the cheeks, and the 
whole anterior part of the neck. Sometimes, the tubercles 
are developed on one or both of the angles of the lips ; thick 
incrustations succeed to the ulcerations, and it is with the 
greatest difficulty that the patient can open his mouth. The 
nose, which is rarely the primitive seat of this variety of 
Lupus, is however, not exempted from its attacks, and in many 
cases the scabs which are there formed, carry off with them 
on their disengagement, portions of its alae or its extremity. 
When the scabs are removed under a well-regulated treatment 
they are not replaced by others. Sometimes the surface is 
rough, and studded with small, dull-red tubercles; at others it 
presents a more healthy appearance, and becomes covered 
with small thin desquamations, and a firm white cicatriza- 
tion takes place at several points. In this state of the cure, 
when the ravages of the disease have been extensive, the face 
presents a remarkable appearance ; there are a number of ir- 
regular scars, sometimes of a large size, of a white colour* 
tense, shining, thick in some spots, and so thin in others as t 
appear transparent. These latter characters occur on parts 
that have been attacked several times, and where the cica 
trices have been destroyed by successive ulcerations. Thes 
cicatrices are almost always formed between tubercles, t 
which they seem to serve as connecting links. At other times 
blackish scales may be observed on different points of thei 
circumference, which often remain for a long time. 



lupus. 317 

This variety of Lupus may also occupy large surfaces on 
the breast, the limbs, the anterior part of the thighs, and even 
on parts that are seldom the seat of this form. 

2. Lupus destroying the subjacent parts. ■ — This variety 
principally affects the nose, and is developed either on its alae 
or extremity; in a majority of cases its appearance is preceded 
by redness and swelling, accompanied with coryza. One of 
the alae swells and becomes painful, and is the seat of a livid 
redness. A slight ulceration takes place, a small scab is form- 
ed; if this is picked off, it is replaced by another which is 
thicker, and each time that it is removed it occasions a loss of 
substance, but little perceptible at first, but very visible after 
a short lapse of time. This redness and swelling often ex- 
tends, and the parts become covered with a scab which gra- 
dually augments in thickness; the patient experiences but 
little pain, the skin and the cartilages are destroyed under the 
scab, on removing which, an ill-conditioned ulcer will be seen, 
which discharges great quantities of a sero-purulent fluid. A 
foetid discharge often takes place from the nose, the loss of 
substance is not easily discoverable from the swelling, but when 
this diminishes it is very visible. In other cases there is 
neither coryza nor swelling; a single tubercular, red, smooth, 
soft point is developed, and sooner or later ulcerates. 

The extent of the destruction is very various; sometimes 
almost all the nose disappears; at others, the extremity alone 
is destroyed ; but the disease does not confine its ravages to 
this point only: tubercles form on the cicatrices and new ul- 
cerations succeed them. The parts that were before exempt, 
are now entirely destroyed, and the nose may disappear even 
to the septum itself; a single opening leading to the nasal fossae, 
replaces this part when it is entirely wanting. Oftentimes 
the nose is only diseased at its surface, but in an equal man- 
ner, so that in place of an organ of the usual size, there may 
be seen one of small dimensions and pointed, the nostrils of 
which have a tendency to become closed up; it is always red, 
except at the angle where the alae join the septum; at this 
place the projecting cartilage presents a yellowish hue, which 

41 



818 LUPUS. 

is very perceptible through the transparent cicatrix. But 
this disposition to closure of the nostrils is still more remark- 
able in Lupus accompanied with hypertrophy. In other cases 
the nose is not lessened in this manner, but appears as if a 
part of it had been removed with a cutting instrument. 

The destruction of substance is not in proportion to the du- 
ration of the disease; sometimes, after it has lasted several 
years, a small part only may be found wanting, whilst in other 
instances it may be entirely eaten away in from ten to fifteen 
days. We seen a case under the care of M. Biett, that was very 
remarkable for the rapidity of the ulceration; it was that of 
a woman aged about thirty-six, in whom this disease had de- 
stroyed in a few months, a part of the left side of the nose; 
the disease was checked by means of the Pate arsenicale ; 
but the extremity assumed a livid red colour, scabs were 
formed in the nasal fossae, which also discharged a puriform 
fluid. This livid red colour of the end of the nose sometimes 
disappeared, and again became very strong. It much resem- 
bled the appearances produced by Jicne rosacea, but it shoul 
be remembered that there were no tubercles. Finally, thi 
colour became deeper, a slight ulceration took place, followed 
by a scab, which in a few days was very thick, at the same 
time the patient suffered violent pain. This scab was removed 
four or five days after its formation by means of lotions and 
emollient cataplasms, but the extremity of the nose was al 
ready destroyed. The disease was checked with a solutior 
of the acid nitrate of mercury; but about three weeks after 
wards, this part again assumed a red colour, and fresh ulcera 
tions commenced. A red point appeared on the right side o 
the upper lip, which was very painful, and was soon coverec 
with a thick scab. The ulceration rapidly advanced, and 
part of the lip was destroyed in fifteen days. Antiphlogis 
tics, lotions, with Labarraque's liquor, having produced nc 
effect, the disease was again put a stop to by the use of th 
Pate arsenicale. From this case it may be seen, how rapi 
the course of this disease may be, and also that it is not alway 
preceded by tubercles, A morbid redness with a slight tume 



lupus. 319 

faction of the end of the nose, were the only forerunners of 
the ulceration and destruction of this part, and on the upper 
lip these only preceded the ulceration by a few days. 

In almost all the cases of Lupus of the nose, there exists, 
at the same time, an affection of the mucous membrane of the 
nasal fossa?; and even, in some cases, all the septum may be 
destroyed before the external part of the nose has materially 
suffered. At other times this destruction commences in the skin, 
extends to the pituitary membrane, involves all the mucous 
membrane of the nostrils, and reaches that of the palate, and 
even may attack the gums, and there occasion loss of sub- 
stance. We have spoken of those cases where the nose only 
was affected, but too often the disease, at the same time, 
spreads over the face, and produces terrible ravages. 

Lupus with Hypertrophy . — This variety presents many 
remarkable phenomena; it usually commences on the face, 
(which is almost exclusively its seat,) by soft, indolent tuber- 
cles, which are not very prominent, though they are numer- 
ous; they occupy large surfaces, a considerable portion of the 
cheek, for instance, and sometimes the whole face; they do 
not ulcerate at their summit, at least very rarely, but their 
base gradually enlarges, the skin and subjacent cellular tissue 
become the seat of an indolent engorgement, so that the 
swelled and diseased surfaces present a sort of puffiness that 
is very remarkable; after a certain time the face is studded 
with reddish points, which are tubercles, that, from the swell- 
ing of the subjacent parts, do not rise above the surface; here 
and there white points may be seen; these are scars, which 
have succeeded to former tubercles. What is very singular in 
this disease, is the formation of these scars, which supervene 
on small circumscribed tumours, without these having been 
the seat of ulceration or incrustations. In fact, the tubercles 
are the seat of an insensible and constant exfoliation, and it 
appears as if all the layers of the hypertrophied skin are suc- 
cessively pushed outwards, and gradually destroyed by suc- 
cessive desquamations. 

The face may, under such circumstances, acquire a size that 



320 lupus. 

is truly astonishing; the cheeks are soft and flabby, they pre- 
sent a tissue which preserves to a certain degree any im- 
pression made on it by the finger, somewhat resembling the 
state of these parts when they are affected with Elephan- 
tiasis. The forehead and eyelids are swelled, and the eyes 
hidden under these tumefied parts, are buried as it were, in 
their orbits. The lips form two great cushions, and their mu- 
cous membrane is exposed from this over-distention. Even* 
the ears may participate in this general puffiness of the face. 

We have seen among other cases, this state even carried to 
a greater degree in two patients in the Hospital of St. Louis, 
whose appearance, as may be supposed, was at once singular 
and frightful. 

These tubercles, as we have already said, rarely become the 
seat of ulceration ; when this does take place, it is usually very 
slight, and forms thin and adherent scabs. Their surfaces are 
generally dry ; they present a bluish colour, and are the seat 
of a constant, but slight exfoliation. 

The disease may last for an indefinite time, but when the 
parts return to their natural state, which never takes place 
spontaneously, and is only the effect of a long and well-con- 
ducted treatment ; a greater degree of vitality is established in 
them ; the tumefaction gradually diminishes, a slow resolution 
occurs in the tubercles ; the circulation becomes more active 
in the skin, which insensibly regains its natural texture and 
appearance, though it is never wholly restored to its former 
state. 

There is a variety of this form of Lupus which is entirely 
different, in which the ulcerations, that have succeeded 
either to the livid spots, or to the tubercles, become covered 
with small, red, soft tumours, that are somewhat fungous, 
and very prominent, the effect of which on the face is very re 
pulsive. This variety is generally very severe. 

These different varieties of Lupus may simultaneously exist 
on the same individual, and the first form may attack a part o 
the face, whilst the nose is at the same moment destroyed by 
the second, and the other cheek be the seat of the third. There 



lupus. 321 

are even cases where Lupus extends its ravages on the sur- 
face, and is also accompanied with a real state of hypertrophy. 
Under such circumstances, great destruction often occurs, a 
terrible, and, at the same time, not uncommon accident, is the 
destruction of the lower eyelid, by one or more tubercles ap- 
pearing on it, succeeded by ulceration. The skin of the cheek 
then becomes continuous with the conjunctiva of the ball of 
the eye; and it may readily be conceived that this state is not 
only repulsive, but that it entails much misery on the patient. 
In fact, without speaking of the epiphora, which is inevitable 
in such cases, the eye being in a great measure unprotected, 
becomes the seat of a chronic inflammation, the conjunctiva 
thickens, the cornea is rendered opaque, and blindness ensues. 
In some cases, the whole of the eyelid is not destroyed, but 
the small ulcerations, of which it is the seat, cause Ectropion 
when they cicatrize. The eyes then appear to be twice their 
natural size, which, joined to the vivid redness of the everted 
lids, adds much to the already hideous aspect. 

In other instances, the thick scabs, which have remained 
adherent to the nose for a long time, discover on their falling 
off, not only a greater or less degree of destruction of parts, 
but also a swelling which would obliterate the nostrils, either 
from the tumefaction itself, or from the cicatrices that are 
formed, if great care be not taken to prevent it. 

At other times the ulceration may destroy a great part of 
the angles of the mouth, and a considerable portion of the lips: 
these surfaces, when deprived of the scabs, become contracted, 
and solid scars are formed, diminishing the opening of the 
mouth in a considerable degree. 

Erysipelas of the face is often complicated with this disease. 
In some cases it may occasion serious consequences; but ge- 
nerally, instead of adding to the danger, it may mitigate the 
severity of the Lupus. We have, in fact, seen more than 
once, particularly where this latter disease is attended with 
hypertrophy, the appearance of the exanthematous affection 
followed by the most advantageous results, the diseased sur- 
faces changed their aspect, the vitality of the skin became 



322 LUPUS. 

greater, the resolution more active, and the disease terminated 
in a manner as happy as it was unexpected. 

Finally, in very severe cases, where the Lupus goes on in- 
creasing, and destroys not only the skin, but also the carti- 
lages and bones, extending its ravages on all sides, the pa- 
tients may likewise experience symptoms of a chronic gastro- 
enteritis, and sink under the effects of a slow fever, accom- 
panied by a colliquative diarrhoea. This fatal termination 
is extremely rare, and the Lupus may last for years, constantly 
extending its attacks to portions of sound skin, or again de- 
stroying the newly-cicatrized surfaces. 

It may affect the cartilages of the nose, and yet not injure 
the bones; it appears, indeed, that this terrible disease apper- 
tains more particularly to the skin. We have seen a great 
number of patients in the Hospital of St. Louis, who had been 
suffering from Lupus for years, without their having been 
subjected to any energetic treatment, and yet we have rarely 
met with any destruction of the bones, except of those of the 
nose, which, on the contrary, are often so entirely destroyed, 
that nothing is to be seen but a triangular opening, divided 
into two parts by the remaining portion of the septum. 

Causes. — Lupus particularly affects children and adults; it 
is very seldom developed after the age of forty; it indiscrimi- 
nately attacks both sexes, and in about an equal proportion. 
It is more frequently met with in the country than in cities, 
without our being able to assign any reason for this singular 
predilection, except it may be in the badness of the food with 
which the inhabitants of the former are nourished, or in the 
unhealthiness of their places of abode. It very often oc- 
curs in young scrofulous children, and lasts till beyond the 
age of puberty. Sometimes those individuals who were at- 
tacked in infancy, may be again affected with it in after life. 
Nevertheless, if it is a fact that the occurrence of Lupus of- 
ten coincides with a scrofulous constitution, it is also true that 
it may manifest itself in persons in the flower of their age, 
who are robust, and have always enjoyed the most perfect 
health. As to the anterior existence of diseases of the skin. 



lupus, 323 

among others the Porrigo larvalis, they do not seem to have 
any effect on the appearance of Lupus. 

The variety designated by M. Biett, under the name of 
Lupus with hypertrophy, is more especially connected with 
a scrofulous diathesis. Finally, the causes under the influ- 
ence of which the disease has appeared to have been develop- 
ed in some cases, can only be regarded as exciting causes. 

Diagnosis. — Lupus may be confounded with several erup- 
tions which have their seat in the face, and from which it is 
very important to distinguish it. 

The circumscribed indurations that succeed to the pustules 
of Jlcne, may in some instances be mistaken for the commenc- 
ing tubercles of Lupus; if their red colour, the erythematous 
areola that surrounds them, and the pre-existence of pustules, 
which are still to be found in their vicinity, were not sufficient 
characters to distinguish them from the livid, indolent tuber- 
cles of Lupus, whose appearance is preceded by no other le- 
sion than a light violet tint of the skin. 

Certain cases of Lupus, and particularly that connected 
with hypertrophy, may be mistaken for Elephantiasis grseco- 
rum, but the fawn colour of the skin, the form of the tuber- 
cles themselves, presenting, as they do, the appearance of 
small, deformed, unequal tumours, and the partial enlargement 
of certain portions of the face, distinguish Elephantiasis from 
this variety of Lupus, which is accompanied, it is true, by a 
kind of analogous swelling, but it is equal and uniform. The 
same characters will serve to aid the diagnosis in cases where 
the Elephantiasis is ulcerated in several points, and presents 
here and there, blackish scabs. These ulcerations are always 
more superficial than those of Lupus, and have not the same 
tendency to extend to the sound parts. Elephantiasis may 
also exist, in a majority of cases, on many other portions of 
the body, besides which, when it has arrived at this stage, it 
is accompanied by a crowd of symptoms, local and general, 
which are widely different from those of Lupus. 

The scabs that cover the ulcerations in Lupus might, on a 
superficial examination, be taken for those of Impetigo; but 



324 lupus. 

besides that these latter, which are yellow, prominent, rough, 
and but little adherent, especially on the face, differ greatly 
from the brownish, thick, and adherent crusts in Lupus , 
there can remain but little doubt when attention is paid to the 
lesions which have preceded both the incrustations and the cica- 
trices in Lupus, and. finally to the ulcerations themselves, which, 
in the latter disease, succeed the disengagement of the scabs. 

In all these cases, a little attention will always obviate any er- 
ror; but there are two diseases, from which it is often much more 
difficult to distinguish Lupus, and whose diagnosis is of the 
highest importance to verify; these are Noli me tangere and 
certain varieties of Syphilis. 

Under the name of Noli me tangere have been confounded 
Lupus and the cancerous affections of the face; there exists, 
however, strong differences between these two diseases, and, 
as has been said by M. Biett, (a long time since,) the term of 
Noli me tangere should be restricted to the cancerous affections 
alone. 

The hard cancerous tumours, which, although indolent, are 
often painful, that appear in persons advanced in age, on the 
lips, cheeks or nose, where they remain for a long time with- 
out ulcerating, offer, it is true, much resemblance to those of 
Lupus; but this latter disease is scarcely ever developed in 
elderly persons, and, on the contrary, this is the most com- 
mon period for the attacks of the Noli me tangere. This dis- 
ease commences by a single tubercle, whilst there are in most 
cases, several in Lupus. In the latter, the tubercles are situ- 
ated in the most superficial layers of the skin, and are always 
indolent; cancerous tubercles are surrounded by a hard and 
circumscribed base, and are generally the seat of very acute 
lancinating pains. Finally, the Noli me tangere is accom- 
panied by an inflammatory swelling of the soft parts, it is usu- 
ally exasperated by cauterizations, and when once ulcerated, 
it not only involves the skin and cartilages of the nose, but 
it also attacks the bones and injures them deeply, phenomena 
that are never observable in Lupus. Cancerous ulcers are 
prominent, humid, and painful; they present a fungous as- 



lupus. 325 

pect, and do not become covered with dry, thick scabs, like 
Lupus. 

Syphilis occurs on the face with symptoms so analogous to 
those of Lupus, that they may cause much embarrassment at 
first. When these two affections are only characterized by 
tubercles, whose apex is not ulcerated, it is sometimes very 
difficult to discriminate them; nevertheless, the syphilitic tu- 
bercles are larger, rounded, and of a copper-red colour; they 
are not the seat of exfoliation, and even have less tendency to 
ulceration than those of Lupus, which are smaller, softer, 
more flattened, accompanied with a slight tumefaction of the 
skin, and almost always covered with a small epidermic scale. 
Finally, syphilitic tubercles on the face, which are conse- 
cutive symptoms of a venereal affection, are seldom seen, ex- 
cept in persons of a certain age, whilst Lupus, on the contrary, 
most generally occurs in young subjects. We shall not give as 
a diagnostic character, one that may be found in a recent 
work, where it is laid down, that one of the distinctive signs 
of Lupus, is its frequent occurrence on the cheeks and alae of 
the nose; examples of the contrary are too common, and the 
author must have observed but few cases of this affection, not 
to know that the presence of tubercles on the alae of the nose, 
is, on the contrary, in a great number of instances, an almost 
pathognomonic symptom of Syphilis. 

As to the syphilitic ulcerations which succeed these tuber- 
cles, they also differ in a marked manner from those of Lupus; 
they are deep, their edges are swelled, of a copper-red colour, 
and regular; those which follow the tubercles of Lupus pre- 
sent a dull red colour, and only appear to occupy the superfices 
of the skin. As to those which characterize that variety of 
Lupus which attacks the subjacent parts, and which approaches 
still nearer in appearance to syphilitic ulcers, particularly in the 
cases where the nose is entirely destroyed, it differs from them 
in the manner in which this destruction takes place. Thus, 
in Lupus, the skin is usually first affected, the cartilages and 
bones are consecutively attacked, and in general not till after 
the disease has lasted for a long time* In Syphilis, on the 

42 



326 lupus. 

contrary, at least in such circumstances, the disease begins by 
attacking the bones; it is not till after they have been affected 
with caries and necrosis, that it extends to the skin, added to 
which, the work of destruction, in all these tissues, goes on in 
a much more rapid manner. Finally, whether it appears in 
the form of tubercles, or is characterized by the presence of 
ulcerations of different extent or depth, Syphilis is almost 
always accompanied by well-marked concomitant symptoms, 
among which may be mentioned, pains in the bones, exosto- 
sis, iritis, and ulcerations of the pharynx or soft palate. 

Prognosis. — The prognosis of Lupus is always unfavour- 
able; not because this disease endangers life, but from its 
being so obstinate in a majority of cases, as not to yield until 
it has caused a destruction of parts to a greater or less degree, 
and from its cure being attended with numerous, deformed, 
and indelible scars. It becomes much worse, when a cure is 
not attempted before it has already made considerable progress, 
or when it is accompanied by much hypertrophy, or when 
ulcerations succeed on the recently healed parts, and the cica- 
trices are destroyed. Besides, when these cicatrices remain 
soft, and of a bluish colour, and give a sensation of fluctua- 
tion on being touched, or when they are circumscribed by tu- 
bercles, a return of the disease is to be expected; and we have 
several times seen M. Biett predict a renewal of the ulceration 
from the above characters. The establishment of the process 
of menstruation does not produce effects of sufficient import- 
ance, to permit us to base any prognosis on it. 

Treatment. — The treatment of Lupus is both general and 
local. The general treatment is, in most cases, very simple; 
it consists merely of bitter ptisans, the administration of baths, 
and careful attention to the diet, &c. hence, it will seldom be 
sufficient of itself to overcome this severe and obstinate dis- 
order. Nevertheless, in some cases, general treatment ap- 
pears to be important. Thus, when Lupus attacks persons 
who are evidently scrofulous, it is proper to place the patient 
on an appropriate course of treatment: and advantage will be 
derived from a solution of the hvdro-ehlorate of lime, in the 



lupus. 327 

proportion of a drachm to a pint of water, which has been 
proposed as a substitute for the hydro-chlorate of barytes, 
whose effects are often pernicious; the patient is to take a 
spoonful every morning, increasing it in the same ratio every 
four or five days, till it is raised to twelve spoonfuls a day, 
or even more. For the same purpose, recourse may be had 
to ferruginous preparations, the sulphuret of iron for example; 
the patient should also be put on a generous diet, and reside 
where the air is free and pure. 

Under other circumstances, to hasten the resolution of the 
tubercles, active means may be resorted to, which employed 
in conjunction with a well-directed local treatment, have 
sometimes powerfully contributed to the cure of this disease; 
such as the animal oil of Dippel, which is to be given in the dose 
of five or six drops, and gradually increased to twenty or 
twenty-five drops ; Feltz's decoction, the Asiatic pills, Pear- 
son's solution in the dose of a scruple, and afterwards increas- 
ed to a drachm; that of Fowler, beginning with three or four 
drops, and augmenting the dose every eight days in the same 
proportion, until it has reached twenty to twenty-five drops 
a-day; but the utility of these different remedies are very 
doubtful, if they be not aided by local applications. 

As to other general means, they consist in well-directed 
hygienic means; it is important that the patients should not 
expose themselves to too great a degree of heat or cold; for 
under such circumstances the cicatrices are very apt to open, 
especially in women. It is advantageous to re-establish the 
menstrual evacuation if it has ceased, and to endeavour to 
keep up their periodical return. 

The local treatment consists, 1st. In resolving applications, 
which are to be somewhat irritating, in order to restore the 
vitality of the skin, and hasten the resolution of the tubercles. 
2d. In caustics, for the purpose of changing the state of the 
diseased surfaces, to restrain the ravages of the ulcerations, 
and to obtain persistent cicatrices. 

The resolving applications should be resorted to, when the 
tubercles are not ulcerated, and when they exist around the 



:*2S lupus. 

cicatrices. They are the only remedies that are effectual in 
Lupus with hypertrophy. Those preparations which best 
fulfil this end, are the proto-ioduret of mercury mixed with 
axunge, in the dose of 9i. to 3ss. in axunge ^i. The deuto- 
ioduret of mercury in the proportion of from twelve to fifteen 
grains to a scruple, for the same quantity of axunge. Slight 
frictions with these ointments are to be made on all the parts 
that are covered with tubercles. But the remedy which suc- 
ceeds best, and appears to have the greatest effect in hastening 
resolution is the ioduret of sulphur in the proportion of gr. xii. 
or 9i. to axunge §i. We have several times seen it employ- 
ed by M. Biett; and among others, in two very severe cases 
of Lupus with hypertrophy; frictions with this ointment 
modified the disease in a very advantageous manner. 

A modern author appears to fear that after the use of these 
frictions, that Erythema or even Erysipelas maybe developed, 
but such an objection is puerile, these inflammations cannot 
occasion any ill consequences, and they may even be salutary. 

Sometimes these means are not sufficiently powerful; or 
there may be some inconveniences in persisting in their use, 
particularly where they have not occasioned any amelioration, 
or where the tubercles have ulcerated at their summit. In the 
latter case, it has sometimes appeared that they only increased 
the ulcerations. We are therefore obliged to resort to caus- 
tics; these are the animal oil of Dippel, the nitrate of silver, 
caustic potash, butter of antimony, Dupuytren's powder, the 
arsenical paste of Frere Come, and the acid nitrate of mer- 
cury. 

Whatever may be the caustic employed, there are certain 
rules which must be attended to. In the first place, it may 
readily be conceived that when the disease is extensive, cau- 
terization should only be practised on a small spot at a time, 
and the diseased surface successively attacked. On the other 
hand, the state of these surfaces must be considered, before 
these preparations are applied. Thus, when the surface 
ulcerated, humid, and clean, they may be used at once; if on 
the contrary, it is covered with scabs, these must be removed 



lupus. 329 

by means of emollient cataplasms; and finally, if the points it 
is wished to cauterize are the seat of indolent tumours, which 
are not ulcerated; if they present livid, dry patches, accompa- 
nied with a considerable tumefaction of the skin, or if it is a 
case of Lupus with hypertrophy, the surface should be re- 
moved by the application of a blister. 

The animal oil of Dippel acts rather as a stimulant than 
as a caustic, but it often modifies in an advantageous manner, 
the parts to which it is applied. It is particularly serviceable 
in cases where the nose is the seat of an indolent and chronic 
swelling, presents a livid colour, and is constantly subject to 
an epidermic exfoliation. It is applied by dipping a camel's 
hair pencil in the liquid, and drawing it lightly over the dis- 
eased spot; this is to be repeated several times. We have 
often seen it produce a marked amelioration, but never a com- 
plete cure. 

Cauterizations with the nitrate of silver, caustic potash, 
and butter of antimony, are followed by very variable re- 
sults, and they are never as efficacious as the following reme- 
dies. 

Powder of Dupuytren, which is a mixture of the proto- 
chloride of mercury, and arsenious acid, in the proportion of 
one or two hundredths of the latter, and is a caustic which is 
at once mild and efficacious; it is particularly serviceable in 
Lupus when of little extent, occurring in children, women, 
and persons of irritable habits. To apply it, the surface is to 
be lightly sprinkled with it, by means of a powder-puff, so as 
to cover it about half a line or more. Although the use of 
this caustic seldom causes any pain, and is unaccompanied 
with any swelling of the surrounding parts, it is always well 
to apply it to small surfaces at a time. These should not ex- 
ceed a quarter of a dollar in size; it forms a grayish adherent 
incrustation, which remains attached for a long time, without 
it is removed by means of emollient applications. 

Arsenical paste of Frere Come is a still more valuable and 
energetic remedy, and requires to be used with caution. It is 
particularly applicable to cases of Lupus of long standing and 



330 lupus. 

obstinate character, whose ravages cannot be checked by 
milder means. It is also very useful in that severe variety of 
this disease, which destroys the tissues to some depth. It is 
applied by mixing a small quantity on some hard body, as a 
slate or saucer, with a little water, and by means of a spatula 
this liquid paste is to be spread on a surface not exceeding 
half an inch in diameter. We have seen it used a great num- 
ber of times in the Hospital of St. Louis, and we have never 
met with a single instance in which its application was follow- 
ed by those general symptoms of a severe and dangerous cha- 
racter, which are usually supposed to be its usual concomitants; 
but in almost all the cases, this cauterization occasions local 
effects, constituting a series of symptoms, which, though appa- 
rently alarming, yield with great facility and promptness to 
the proper remedies. Thus, the application of this substance 
is generally followed by Erysipelas, which, though sometimes 
light, may be very severe; the whole face becomes enormous- 
ly swelled; the patient complains of violent head-ache, but at 
the end of a few days, by means of irritating pediluviums, 
and a few leeches behind the ears, by diet, emollient and lax- 
ative injections, without, in most cases, being obliged to re- 
sort to general blood-letting, all the symptoms disappear, 
the face returns to its natural colour, and the only remaining 
mark of the caustic is a blackish, thick, very adherent scab, 
which remains attached for a very long time. 

Finally, the acid nitrate of mercury is also a very ener- 
getic caustic, and has also been employed with good success 
at the Hospital of St. Louis. It, like the former, causes an 
erysipelatous inflammation, but of less violence, and more 
easily subdued. It may be applied, not only to the ulcers, 
but also to the tubercles, and on the cicatrices, if they are soft, 
bluish, and fluctuating, menacing a fresh ulceration. It is 
used by passing a small dossil of lint, dipped in the solution, 
over the diseased surface to the extent of a dollar, or lint may 
be applied to the part, and then moistened with the caustic. 
The surfaces immediately assume a white colour, and in a 
short time a yellowish scab is formed, having but little adhe- 






LUPUS. 331 

rence, which becomes disengaged in from eight to fifteen days. 
This cauterization is very painful; it, however, lasts but for a 
few instants. 

As to the actual cautery, it is seldom followed with advan- 
tageous results, and often indeed aggravates the disease; the 
cartilages swell, and become the seat of a chronic inflamma- 
tion, which only adds to the violence of the original disease. 

Whatever may be the caustic employed, when the scabs 
are detached, they leave a healthy ulcer, and cicatrization soon 
takes place; but in a majority of cases, one application is not 
sufficient; they must be repeated again and again, perhaps for 
years, if the disease is of any great extent. In such cases, the 
greatest patience is necessary, as well on the part of the phy- 
sician, as of the patient; perseverance will generally effect a 
cure. We have seen among others, in the Hospital of St 
Louis, a case of very severe Lupus in a young girl, that had 
involved the whole face, and which only yielded, after a treat- 
ment of several years, during which more than fifty successive 
cauterizations Were used. 

There are some indispensable precautions to be used in the 
treatment of Lupus; for example, it is of the highest import- 
ance to watch very closely the formation of the cicatrices, to 
prevent their occasioning great deformities, or closing up na- 
tural openings. Thus, among others, great care must be taken 
to prevent the closure of the nostrils; this may be obviated by 
the introduction of small pieces of prepared sponge. This 
means should be continued for a long time, for it should be 
recollected that the tendency in these openings to become 
united, not only exists during the period of ulceration, but 
also for a long time after the formation of the cicatrices. 

Finally, the local and general treatment of Lupus is some- 
times advantageously assisted by simple or vapour baths, but 
the most useful of these means are douches of vapour, parti- 
cularly in Lupus with hypertrophy. 



( 332 ) 

ORDER X. 

PELLAGRA. 

WE have never seen this affection, which is peculiar to 
certain parts of Italy; the description we are about to give, is 
principally drawn from the clinical lectures of M. Biett, and 
from an article by Dr. Holland, in the eighth volume of the 
Medico-Chirurgical Transactions. 

M. Biett, who has seen the Pellagra in Italy, considers it 
as symptomatic of lesions of the internal organs, and particu- 
larly of the digestive canal. This opinion is also maintained 
with great talent by Dr. Giovani Strambio, in a work which 
he has recently published. 

Pellagra occurs epidemically in the plains of Lombardy, 
and the name of Pellagrosi has been given by the Italians to 
the unhappy sufferers from it. The cutaneous affection only 
exists during the spring and summer, and disappears towards 
the middle of autumn, but the other symptoms are constant. 
Hence it is during the spring, that physicians who visit Italy 
to study this disease, should go to that country — at Milan, 
they will find numerous opportunities of observing it. 

The march of Pellagra is always chronic, and its duration 
is generally several years. A state of both moral and physi- 
cal depression, loss of appetite, pains in the epigastrium, diar- 
rhoea, vague and dull pains in the limbs, great lassitude, cepha- 
lalgia and stupor are the usual symptoms that precede the oc- 
currence of the cutaneous affection; this manifests itself on the 
back of the hands or feet, on the limbs, neck, and but rarely 
on the face, in the form of small, red spots, which gradually 
extend, and are accompanied by a slight tumefaction of the 
skin, as well as a feeling of tension and itching. The redness 
of the spots is deeper than that of Erysipelas, and their surface, 
which is at first shining, soon becomes covered with scales 



PELLAGRA. 333 

resembling those of Psoriasis. After a certain time, the spots 
unite, and thus form large patches. The skin in these places 
is thickened, and presents rents and fissures of different depths. 
The scales gradually fall off, and discover a red and shining 
surface; fresh scales are rarely formed again that year. To- 
wards the end of the summer, or the commencement of au- 
tumn, the skin regains its natural state, but the general health 
is rarely completely re-established. 

The general symptoms which accompany the eruption we 
have just described, are almost always those of gastrointesti- 
nal irritation, and among them, diarrhoea is the most remark- 
able; fever is rarely observed, and the menses occur at their 
accustomed periods. 

The following year, the disease reappears with still more 
severe symptoms; the languor and depression are more strong- 
ly marked; the diarrhoea is often very troublesome, the patient 
can no longer undertake his accustomed work; there are 
cramps in the limbs, and other spasmodic symptoms. The 
cutaneous affection also appears, and is of greater extent; the 
fissures are deeper, particularly about the joints of the fin- 
gers, as takes place in Psoriasis inveterata, when it occurs 
on these parts. Towards the middle or end of the autumn, 
these symptoms begin to disappear, but their remission is less 
perfect than that of the preceding year. 

In the third year, the disease returns with additional vio- 
lence; the feebleness is extreme; the limbs, weakened by pain, 
can scarcely support the patient; the diarrhoea continues, and 
there is sometimes a dysentery; anasarca of the inferior extre- 
mities frequently occurs; at other times, ascites may take 
place, or even effusions into the thoracic cavities. Symptoms 
of some affection of the encephalic organs sometimes super- 
vene, as vertigo, noise in the ears, epileptic paroxysms, and a 
state of idiocy or mania ; it appears that when the latter occur, 
the progress of the eruption is somewhat retarded. 

This affection continues to aggravate from year to year, 
until the constitution of the patient is entirely destroyed; 
when a colliquative diarrhoea, and a state of emaciation with 

43 



334 PELLAGRA. 

cerebral symptoms of greater or less intensity terminate the 
sufferings of the patient. The duration of Pellagra is al- 
ways several years, it may be prolonged from six to twelve, 
or even beyond that. It may terminate by a restoration to 
health, provided the proper means are used; at other times 
the disease may end in idiocy or madness, and even in death. 

Dissection. — The examination of the bodies of persons 
who have died from this disease, almost always discovers or- 
ganic lesions to a greater or less extent, and particularly in 
the digestive canal. Nevertheless, (here as in many other 
cases,) the majority of authors who have treated of Pellagra, 
have regarded these lesions, not as the cause of the disease, 
but as the consequences of it 

M. Biett does not coincide in this opinion, on the contrary, 
he considers the cutaneous affection as one of the numerous 
symptoms of a disease in which one or more of the internal 
organs are constantly affected. 

Two cases of dissection of Pellagrosi made at the Hospital 
at Milan, by Dr. Carswell, of Glasgow, who has had the 
kindness to communicate them to us, confirms this opinion, 
which is also held by this gentleman. In these individuals, 
who had presented evident symptoms of chronic irritation of 
the digestive canal, there was a large perforation of the sto- 
mach resulting from a softening of the coats of that viscus; 
other points of the mucous membrane also offered unequivocal 
traces of chronic inflammation. 

Causes. — Both sexes are equally subject to this affection, 
it is confined to adults ; some authors regard it as hereditary. 
It is almost exclusively observed in the lowest class of per- 
sons, particularly among the peasants and those who follow 
agricultural pursuits. The immediate cause of its develop 
ment appears to be a peculiar and unknown condition of the 
atmosphere, or rather of the soil. The humidity and mias 
mata that arises from the marshes where rice is grown, and 
which is cultivated in great abundance in the plains of Lorn 
bardy, joined to the great heat, are perhaps, the principal 
causes of this singular disease. 



PELLAGRA. 335 

Treatment. — The treatment consists above all, in leaving 
the places, and the employment, which are evidently the 
cause of the development of Pellagra; but it is necessary 
that this removal, to be efficacious, should take place at the 
commencement of the disease, at a later period it will not 
effect the desired end. In the advanced stage of the affection, 
the treatment should be conformable to the nature of the pre- 
dominant symptoms, which are those of irritation of the di- 
gestive organs. 



( 336 ) 



ORDER XI. 

SYPHILITIC ERUPTIONS. 

VENEREAL eruptions date from the origin of Syphilis 
itself, or at least they were the first symptoms by which this 
disease manifested itself in Europe. In fact, the first authors, 
who wrote on Syphilis, towards the end of the fifteenth cen- 
tury only speak of pustules having their seat on the skin, and 
their names of scabby, humid, or ulcerous pustules, seem to in- 
dicate that they were aware of the different species. Con- 
founded among the multitude of forms with which Syphilis 
appears, they were for several centuries without attracting 
particular attention, or were at most, but slightly noticed by 
authors. At the commencement of the nineteenth century, 
Alibert constituted a distinct family of them, which he termed 
Syphilides ; but by this denomination he meant all the altera- 
tions of the skin produced by the venereal virus; and in 
grouping the species from their form, and often indeed, from 
their different states, without paying attention to the primitive 
lesions, he has united varieties which are essentially distinct, 
and admitted species, ( Syphilids ulcereuse, ) on characters 
that are merely secondary, (ulcerations,) and which may also 
succeed to wholly different alterations. 

For some years past, M. Biett in attending particularly to 
these diseases, has studied their course and development with 
great care ; and by selecting their primary characters, he has 
grouped them from their elementary lesions, and has succeed- 
ed in establishing distinct varieties, exempt from all confusion. 
We shall treat of these diseases according to his plan. We 
attach the denomination of Syphilitic eruptions, (Syphi- 
lides,) to the venereal affections, which having the skin for 
their special seat, constitute real eruptions, both from the ex- 



SYPHILITIC ERUPTIONS. 337 

tent of the surfaces they occupy, from the primary alterations 
which may all be referred to the elementary lesions of erup- 
tions of another nature, but rejecting all those prominent pro- 
ductions, all those symptoms which appear to us to have been 
erroneously confounded with the venereal eruptions, only ad- 
mitting among them those ulcerations which succeed to scabs, 
or occur on the summit of a tubercle. 

Thus, the venereal chancre, (which takes place without being 
preceded by any elevation of the epidermis, or vesicle, as was 
a long time since observed, and has recently been again in- 
sisted on,) the ulcers, warts, excrescences, &c. cannot be ad- 
mitted in this class. They constitute essential and wholly 
different symptoms. 

We mean by Syphilitic eruptions, any true eruption ap- 
pearing on the skin under the influence of the venereal virus. 
They may be exanthematous, vesicular, pustular, tuber- 
cular, papular, and scaly. They are sometimes primary, 
that is to say, that they accompany the other symptoms, and 
are developed with them a short time after the infection; in 
some cases, they may be the only symptoms by which the 
Syphilis manifests itself. But in general, they are consecu- 
tive,- that is to say, they are developed either immediately 
after the disappearance of the primary symptoms, or not for 
weeks, months, or years. 

Their march is usually chronic; when they are primary, 
however, they may pursue an acute course, particularly when 
they are exanthematous. 

All ages are subject to them, from the infant who, punished 
for the faults of those who gave it birth, brings into the world 
an affection which soon manifests itself on all its body, and 
generally hurries it to an untimely grave ; to the old man, 
who is astonished to find, that he is then to pay for a pleasure 
he had forgotten. 

The symptoms occasioned by these eruptions, may be di- 
vided into three classes: to the first belong those which are 
common to the whole order; to the second belong the peculiar 
features of each species. Thus the papular variety presents 



338 SYPHILITIC ERUPTIONS. 

different appearances from the pustular, &c. Finally, in the 
third, we shall speak of that assemblage of general symptoms, 
the melancholy and constant attendant on these eruptions. 

Common symptoms. — These diseases generally present 
a copper colour; in some cases, where they are acute, this 
hue may be less strongly marked, but still they never ap- 
pear with the true inflammatory red tint. They usually 
assume a circular form, whether the eruption appears in small 
isolated patches, or to such an extent as almost to cover the 
extremities. Sometimes the circle is not complete, particu- 
larly in the cases last alluded to, but it is always easy to fill 
up the space in idea, as the part that is wanting is seldom 
more than a small segment of the ring, of which there may 
be seen from a half to a greater proportion. 

The scales are always thin, dry, and grayish; the scabs, 
thick, greenish, sometimes black, and always hard and fur- 
rowed. The eruption may affect all parts of the skin, but the 
face, and particularly the forehead and alae of the nose, the 
back and shoulders, are its usual seats. It has been said that 
the hands and wrists are often attacked, but among the numer- 
ous cases we have had an opportunity of observing, this form 
very seldom occurred. The skin in the intervals, between 
the eruption, is most generally dry, and the patient exhales 
an infectious and peculiar odour. Cold favours their deve- 
lopment, whilst heat represses it. 

Particular symptoms. — We have said that these eruptions 
may assume the exanthematous, vesicular, pustular, &c. form: 
we shall examine these in succession, or at least point out the 
symptoms which characterize each. 

Exanthematous form. — This presents two varieties, the 
one primary and acute, the other secondary and chronic. 

The first, (Roseole syphilitique; Sy phi tide pnstuleuse 
ortiee, Al.) occurs in the form of small, irregular, grayish spots, 
of a copper-red colour, slightly confluent, and disappearing, 
though slowly, under the pressure of the finger. This variety 
principally manifests itself on the body and limbs: it always 
accompanies the primary symptoms, particularly Blennorrha- 



SYPHILITIC ERUPTIONS. 339 

gia. These small spots appear without any general symp- 
toms, sometimes in the course of one night; they are accom- 
panied by a slight itching, and are usually of a transient na- 
ture; they gradually disappear, and only leave a slight gray ish 
tint, which lasts for months. This eruption is usually tran- 
sient, ephemeral, and vanishes in a few days. 

In other instances, this eruption is consecutive on a former 
infection, Maculse syphilitica ; Ephelides syphilitiqites. J 
It also appears on the body and limbs, but may also occur on 
the face, and especially on the forehead. This variety pre- 
sents itself in the form of spots, which, though sometimes ir- 
regular, are generally circular, of a dark copper colour, never 
confluent, and disappearing very imperfectly on pressure. 
Their size in the majority of cases, is about that of half a dol- 
lar; they become covered, in some rare instances, with a slight 
exfoliation, accompanied with a little itching. These spots 
may exist alone, but in general they attend on syphilitic symp- 
toms, having their seat either in the skin or in other tissues. 

This affection terminates by resolution, or by a slight des- 
quamation ; but its patches, notwithstanding the assertions of 
some pathologists, never become ulcerated, and if in some 
rare cases they have been covered with scabs, these' have been 
occasioned by some accidental pustules. 

Vesicular form. — This variety is one of the rarest forms 
of Syphilis. M. Biett, who has seen such a multitude of ve- 
nereal eruptions, has only met with it, three or four times, 
We ourselves, have been fortunate enough to observe it in one 
patient in the Hospital; an account of the symptoms present- 
ed by this young girl, will serve for a description of it. 

J , aged sixteen, of a strong constitution, sanguine tern- 

perament, &c. suffered for some days from an affection of the 
throat; she felt at the back part of her mouth an unusual heat 
and smarting, and had some difficulty in swallowing her sa- 
liva; she soon perceived some small pimples on different partt? 
of the surface of her body. She also had some slight general 
symptoms, consisting of anorexia and feverishness. In this 
state, she presented herself at the Hospital of St, Louis, dur= 



310 SYPHILITIC ERUPTIONS. 

ing the month of July, 1827. The presence of vesicles, (for 
they were, in fact, small elevations of the cuticle, formed by 
the effusion of a transparent fluid,) the appearance of which 
had been preceded by Angina, and some fever, led to the 
belief that it was Varicella. It was the sixth day of the disease, 
the eruption covered nearly the whole body, and the vesicles, 
which left in some places large intervals of sound skin, were 
in different stages of development; some were just beginning, 
whilst others were already shrivelled. There was no other 
concomitant symptom, except the Angina. 

M. Biett having examined this patient with attention, dis- 
covered great analogy between the eruption with which she 
was attacked, and the other cases of the vesicular form of Sy- 
philis he had before seen. A close examination, and the ul- 
terior modifications that the disease underwent, confirmed 
this opinion. In fact, the vesicles were small; their base was 
surrounded by red and copper-coloured areola; they were not 
purely inflammatory; their progress was extremely slow, and 
they occasioned no local symptom, no itching, and scarcely any 
heat. They gradually shrivelled, and the fluid was absorbed, 
In some, it became opaque, concreted, and gave rise to small 
scales, which fell off at different times; but in whatever man- 
ner they terminated, they all left behind them a coppery hue, 
presenting all the characters of syphilitic spots. 

But what added to these singular phenomena, and contri- 
buted in a great measure to elucidate the real nature of the 
disease, was the situation of the throat, at the entrance of the 
patient into the hospital. On the mucous membrane of the 
pharynx was a round ulceration, with a grayish bottom, and 
regular sides, &c. The patient was put on the use of diluents 
alone, in order to see if any characters of a more marked cha- 
racter would develope themselves, but at the end of fifteen 
days, she became discontented, that the disease was not cured. 
There could be nothing learnt from her to confirm the diag- 
nosis, which was, however, sufficiently confirmed by all the 
symptoms that could be observed. 

Persuaded that the disease would become better developed, 



SYPHILITIC ERUPTIONS. 341 

one of us visited her about a month after she had left the hos- 
pital, and found that her whole body was covered with 
syphilitic spots. She was then under the care of an empiric, 
and would not re-enter the hospital. 

Pustular form. — This variety is characterized by the pre- 
sence of small tumours, filled with an ichorous or purulent 
matter. These pustules, the contained fluid of which usually 
concretes and forms scabs, leave a grayish tint, a cicatrix, 
or even an ulceration, on their disappearance. This appears 
to have been the first form in which Syphilis occurred in 
Europe. 

In some cases, these pustules, (psydracious,) are small, 
and aggregated in groups, ( Syphilide pustuleuse miliaire. ) 
They are exceedingly numerous, and are usually elongated 
or conical; their base is hard, and surrounded by a copper- 
coloured areola; they themselves are of a dull red; they 
are developed in a successive manner, and may be seen in all 
their stages on the same individual. Their progress is slow, 
and the inflammation rather slight; nevertheless, it sometimes 
is of sufficient violence to extend to, and destroy the dermoid 
tissue, leaving a small, whitish, circular cicatrix, depressed in 
the centre, and about the size of the head of a pin. It is 
without doubt, from these elementary lesions having been 
confounded with papulae, that these cicatrices, which, at least 
in a majority of cases, are the result of pustules, have been de- 
scribed as belonging to the papular affections. 

This variety may occur on all parts of the surface of the 
body, but is most generally observed on the face and forehead, 
where, at the first glance, it greatly resembles Jicne rosacea; 
the pustules dry, and form a small scab of a grayish-yellow 
colour. This scab becomes detached, falls off, and sometimes 
leaves a cicatrix, but usually, there is nothing to be seen ex- 
cept a slight injection of the vascular tissue. These psydra- 
cious pustules rarely ulcerate ; this only takes place when they 
have become confluent. 

We have seen some instances, and among others, one in 
the hospital, where these pustules were situated on the legs, 

44 



342 SYPHILITIC ERUPTIONS. 

and had been preceded by violet and almost black spots; 
these united, became confluent, and the skin presented true 
sanguine engorgements of the size of, a dollar. In the inter- 
vals, it offered a peculiar corpse-like appearance. These cuta- 
neous ecchymoses occurred on the internal part of the leg. Un- 
der such circumstances, a multitude of the small pustules may 
become confluent, and occasion ulcerations. 

Pustular Syphilis, however, often presents very different 
characters. ( Syphilide pustuleuse lenticulaire, Al. Ecthyma 
syphilitica.) It appears in the form of large pustules, (phly- 
sacious,) which are flattened, isolated, and not prominent ; 
appearing, on the contrary, to be depressed at their centre. 

These pustules are sometimes of the size of a small bean, (S. 
pustuleuse lenticulaire,) occurring in great numbers, and 
very little elevated. Their base is hard, and they contain 
only a small quantity of a purulent fluid, the colour of which 
being of a yellowish-white, forms a strong contrast with the 
surrounding copper hue. They particularly occur on the 
breast and face, and are very rarely followed by ulcerations; 
a small scab is formed, which falls off, and leaves a cicatrix, 
though in some cases, only a livid injection, or a small chro- 
nic induration. Nevertheless, it may happen, that the pus- 
tules of this variety may inflame to a greater degree, the puru- 
lent fluid be more abundant, several of the pustules become 
united and open, the liquid they contain concretes and forms 
thick, greenish scabs, surrounded by a large violet areola; they 
are very adherent, and appear to penetrate into the very sub- 
stance of the dermoid tissue; deep ulcerations always succeed 
to this state of things. 

At other times, the pustules are still larger, (Ecthyma sy- 
philitica, J and are analogous in many respects to those of 
Ecthyma, differing, however, in some of their characters. 
They are generally distinct, and few in number; they occur 
on the limbs, and especially on the legs, in the form of a livid 
spot, of the size of a shilling, or even larger. The epidermis 
becomes elevated to some extent, and is distended by a gray- 
ish, sero-purulent fluid; the tumour slowly increases, and i* 



SYPHILITIC ERUPTIONS, 343 

surrounded by a large copper-coloured areola, very different 
from that of Ecthyma vulgar e, which is of a reddish-purple. 
At the end of some days, it breaks, and effuses a liquid which 
concretes and forms a blackish and very hard scab ; this gra- 
dually becomes very thick, is furrowed circularly, and is of- 
tentimes perfectly round. This development takes place with- 
out any local inflammatory symptoms; there is little heat, the 
surrounding parts are not painful, and the patient only expe- 
riences a little smarting. The scabs are very adherent, and 
may remain for a long time before they become detached. 
When they are disengaged, either naturally, or from the 
effects of emollient applications, they leave round ulcerations, 
which are generally deep, and have regular edges, which are 
constituted of a hard tissue of a violet colour; the bottom is 
grayish and of an unhealthy appearance. These ulcerations 
have no tendency to enlarge. In a short time a scab is again 
formed, and falls off; this continues till from a proper treat- 
ment the incrustations become thinner, the ulcerated surface 
in a cleaner state, and is gradually replaced by a round and 
indelible scar. This is the most common form of pustular 
Syphilis, and is the variety that most usually affects new-born 
children. In such case, the pustules are tolerably superficial, 
flattened, oval, and very numerous; they become covered with 
blackish scabs, which are rather thin, and followed by small 
ulcers. There is at the same time a certain characteristic ap- 
pearance in the expression and features, which it is difficult to 
describe; the skin is dry and harsh, the infants are thin and 
attenuated, their features are wrinkled, so as to give them the 
aspect of little old men; they also exhale an infectious odour. 
. Sometimes the skin which surrounds the nails becomes the 
seat of syphilitic pustules, or they may even form under these 
parts. The pustules are succeeded by ulcerations, from which 
flows a sanious pus that excoriates the surrounding parts; at 
last the nails fall off. They are renewed very slowly, and in 
a diseased state, becoming small, narrow, rough, thin, and 
friable. The ulcerations cicatrize; the skin is of a vivid red 
on these parts, bleeds on the slightest violence done to it, and 



344 SYPHILITIC ERUPTIONS. 

is sometimes the seat of very acute pain. This variety of Sy- 
philis is very often secondary and consecutive. 

Tubercular form. — (Syphilide pustuleuse en grappe, 
Syphilide pustuleuse merisie, Al.) This is one of the most 
common forms of Syphilis. In this variety, the venereal 
eruption manifests itself by tubercles of various sizes, which 
are of a red or copper colour, rounded, flattened, or conical, 
sometimes scattered and distinct, but in the greatest number 
of cases, assembled in groups, or even disposed so as to form 
circles. These circumscribed indurations may remain indo- 
lent for an indefinite time* continuing smooth and polished, or 
else they may be followed by ulcerations which become cover- 
ed with thick scabs, and confined to a small surface, may ex- 
tend in depth, or in other cases, they may attack the skin to a 
considerable distance around. 

It may be developed on all parts of the surface, but it usu- 
ally affects the face; the nose and angles of the lips are so 
frequent a seat of it, that the presence of a tubercle in these 
spots is almost a pathognomonic sign of a venereal affection. It 
sometimes occurs in the eyebrows or scalp, and causes the loss 
of the hair by the ulcerations, which are its almost invariable re- 
sults. We have seen it occupying the whole body. 

It may present a multitude of different states; we shall only 
indicate those which occur the most frequently. Thus, it 
sometimes appears in the form of small tubercles, the size of 
which varies from that of a head of a pin to that of a pea; they 
are round, of a coppery hue, generally arranged so as to form 
perfect circles of different diameters. Each tubercle becomes 
covered with a small, scaly, dry, grayish disk, which does 
not entirely hide its apex; the centre of these circles is healthy. 
This variety is very rarely followed by ulceration; when it 
begins to heal, the tubercles gradually diminish, and become 
less prominent. After some time, nothing is perceptible, 
except a livid red tint, which also disappears. This variety 
is more especially to be met with on the forehead and neck; 
it is never primary. At other times, the tubercles may be 
larger and aggregated in irregular groups; they are oval or 



SYPHILITIC ERUPTIONS, 345 

pyriform, and very prominent; in some instances they are as 
large as a small olive. They are smooth, shining, and polish- 
ed at their summits, never desquamate, occasion no pain, and 
may remain stationary for years. They seldom or ever be- 
come ulcerated. This variety is generally to be seen on the 
face, and particularly on the cheeks or extremity of the nose. 
It is always consecutive. 

In many cases, the tubercles, though few in number, are large, 
distinct, rounded, of a violet-red colour, and surrounded by a 
copper-coloured areola, and are especially developed on the 
face, and more particularly on the upper lip and nose. They re- 
main stationary for a variable period, but finally become painful 
and tense; an erythematous patch appears around them, which 
presents some peculiarities in its colour; as it is not of the 
usual tint of red, but rather borders on a violet. The summit 
of these tubercles soon ulcerates, the ulceration extends in 
depth, and becomes covered with a thick scab ; new tubercles 
are developed whose march is more rapid, the ulcerations be- 
come confluent, and a large surface is to be seen, presenting a 
hard, blackish, and very adherent crust. When this is re- 
moved, it discovers beneath an irregular ulcer, having, how- 
ever, regular edges, constituted of a firm violet-coloured tis- 
sue. The centre is generally deep. New scabs form, and on 
their disengagement show that the work of destruction is go- 
ing on, particularly when seated in parts where the cellular 
tissue is thick. Thus, one of the ala3 of the nose, or a consi- 
derable portion of the lip may be destroyed. The remaining 
surfaces are of a livid red, and present regularly rounded 
forms, as the quarter or half of a circle. In those cases where 
the ulceration has entirely destroyed the nose, so as to leave 
the opening of the nasal fossae on a level with the cheeks, of 
which we have seen numerous examples in the Hospital of 
St. Louis, the disease has always, (or at least in a majority 
of instances,) commenced by an alteration in the bones and in- 
ternal tissues; necrosis, caries, as well as ulcerations of the mu- 
cous membranes took place, and the disease gradually extended 
from within outwards ; the skin soon participated in the mor- 



346 SYPHILITIC ERUPTIONS. 

bid changes of the subjacent parts, becoming thin and ulcerat- 
ed; after this, all obstacles being overcome, the ravages of the 
disease were very rapid. This variety is always secondary. 

Under other circumstances, there are large, red, hard, 
rounded tubercles, scattered over different parts of the body, 
but principally on the back, sometimes equaling a small hazel- 
nut in size. They never become covered with scabs, and may 
remain stationary for a long time; but at the end of a certain 
period, ulceration commences at their summits, gradually ex- 
tending to the surrounding parts, assuming a spiral form in its 
progress, and oftentimes destroying the skin to a great extent, 
healing at one extremity, whilst the other is constantly in- 
creasing, ( Syphilide pustuleuse serpigneuse, Al.) These 
ulcerations, which describe circumvolutions of various forms, 
as segments of circles, circles, zigzags, and spirals, or even 
may appear in the form of cyphers or letters, &c. are very 
superficial, and seldom exceed a few lines in breadth. They 
become covered with thick, hard, black, very adherent scabs, 
and leave indelible and deformed scars. In most cases, new 
tubercles are incessantly forming, which, not all ulcerating at 
the same time, the different stages of the eruption may be 
simultaneously perceptible. We have seen in the Hospital of 
St. Louis, a patient who was entirely covered with this variety 
of syphilitic eruption. His face, scalp, arms, and especially 
his back were seamed by long, mishapen scars, here and there 
interrupted by large, prominent, red tubercles, and from 
time to time the serpentine ulcerations occurred in large num- 
bers. This variety is always consecutive. 

Finally, the tubercular syphilitic eruption may appear in 
another form, which sometimes constitutes a primary symp- 
tom. Here, there are round, thick, flat tubercles, the sum- 
mits of which become the seat of small linear ulcerations, 
(pustules plates, Cullerier. ) Sometimes these tubercles are 
not larger than a small bean, as for instance, when they occur 
at the point of junction of the alse of the nose with the cheek, 
or at the angles of the lips. At other times, on the contrary, 
they acquire a diameter of half an inch, and are several lines 



SYPHILITIC ERUPTIONS. 347 

in thickness ; their colour is a very clear livid red; they occur 
more particularly on the scrotum, penis, pubis, thighs, and 
around the anus. Their summit is soon attacked with a small 
linear ulceration, and appears chapped, exuding a sanious 
fluid, which exhales a peculiarly nauseous odour. Sometimes 
all the scrotum is covered; they are distinct, round, and re- 
markably prominent. In some cases, especially around the 
anus, they become confluent, and present large, but always 
superficial ulcers. This variety may be primary, but it gene- 
rally constitutes a consecutive symptom. 

Papular form, ( Lichen syphililique. J — This consists in 
an eruption of small, slightly prominent, hard, solid eleva- 
tions, containing no fluid, never followed by true ulcers or 
cicatrices, and terminating by resolution and desquamation. 
It may present two different states; one being acute and usu- 
ally primary; the other chronic and always secondary. In 
the first variety, (Lichen syphilitique; Scabies venerea, of 
some authors,) the papulae are very small, numerous, slightly 
conical, sometimes innumerable; they present a copper co- 
lour, and in some places violet areolae, which are confluent 
and give to the skin an appearance of large coppery patches, 
studded with a multitude of small prominent points of a 
lighter colour. They often accompany a gonorrhoea, or are 
developed a short time after the disappearance of the dis- 
charge; this is also the opinion of Carmichael. These pa- 
pulae generally manifest themselves on all parts of the body, 
but especially on the face; their appearance far from taking 
place in a successive manner, as has been stated in a recent 
work, is on the contrary almost simultaneous, and the erup- 
tion is developed in twenty-four or forty-eight hours. It is 
seldom attended with any general symptoms. We have, 
nevertheless, sometimes seen it preceded by cephalalgia, ge- 
neral uneasiness, some fever, and great itching. Among other 
cases, we have observed these phenomena in a remarkable 
degree in a patient at the Hospital of St. Louis, This was a 
young man of about twenty years of age, who had been sent 
to the Hospital de la Pitie, as suffering under small-pox, 



348 SYPHILITIC ERUPTIONS, 

but the eruption evidently presented the characters of papular 
syphilis; it accompanies a gonorrhoea. It is one of the mildest 
forms of the syphilitic eruptions. Bateman has said that the 
papulae sometimes ulcerate, and in a recent work, they are 
described as always terminating in ulceration, when left to 
themselves, and being replaced by violet-coloured cicatrices. 
This is a manifest error. Even when left to themselves they 
may speedily disappear by resolution. It is possible that their 
summit may ulcerate in some cases, as is observed in Lichen 
agrius; when this is the case, they exude a fluid which con- 
cretes and forms extremely light scabs; but these examples 
are exceedingly rare, and besides the ulcerations in Lichen 
never leave scars. It may be said, that they never occur 
after this form of syphilitic eruption. In almost all cases, 
the eruption fades in a few days, and a slight and nearly in- 
sensible desquamation takes place, the papulae disappear, and 
leave small spots which gradually vanish. 

In the second variety, this eruption follows a chronic course; 
it manifests itself by larger papulse, which are flat, of the size 
of small beans, and of a copper colour. They are slightly 
prominent and rounded. They are developed in a slow and 
successive manner, and at first present small yellow spots, 
which gradually become elevated and constitute indolent pa- 
pula?, having no areola at their base, generally occurring in 
large groups, and separated by intervals in which the skin is 
dry and withered ; they excite no itching. They occupy the 
limbs, particularly on their surfaces of extension ; but the fore- 
head and scalp are also their seat in many instances. They 
are always consecutive, and accompany other syphilitic affec- 
tions, especially pustules. It is very rare that this variety 
terminates by retrocession. It is generally of long continu- 
ance, and the apex of each papula becomes covered with a 
dry, grayish pellicle. These fall off, and are renewed until 
the small elevations on which they are situated are reduced to 
a level with the skin, which now only presents spots of a 
grayish-white colour, that are very long before they disappear. 
We have sometimes seen these papulae cover almost the whole 



SYPHILITIC ERUPTIONS. 349 

body, having but few intervals between them; the skin was 
withered, wrinkled and dry, offering a general copper hue ; the 
papulae were the seat of so strongly marked a desquamation, 
that when they were reduced to a level with the skin, the inter- 
vals were hidden by small pellicles, and the disease at the 
first glance, resembled some of the scaly affections. 

Scaly form. — Syphilitic eruptions sometimes manifest 
themselves by dry, grayish scales, situated on small elevations 
of a copper colour, &c. and may appear in the form of almost 
all the scaly diseases. Thus they may present themselves 
under the appearance of Lepra or of Psoriasis. This form 
is always consecutive, it is chronic and generally of long con- 
tinuance. It terminates by resolution or desquamation, never 
by ulceration, and does not leave scars. 

One of its most remarkable forms is when it not only 
presents the patches of Lepra, but these also offer a deep 
grayish colour almost black, which has been described as 
a simple variety of that disease, (Lepra nigricans. J This 
eruption is very rare. We have had occasion to see one very 
remarkable case, in the Hospital of St. Louis; in this patient 
the eruption having disappeared under the influence of an ab- 
dominal irritation, again made its appearance, with all its 
original characters. 

This variety presented the form of round patches, the dia- 
meter of which varied from two or three lines to half an inch 
or more, elevated at the edges, and depressed in the centre, 
offering a very remarkable blackish tint, which was deeper in 
the centre of the patch than on the elevated points that formed 
the circumference. The scales which covered them were 
thin, dry, friable, and having but little adherence; on their 
disengagement they discovered smooth and polished eleva- 
tions. This eruption having gradually disappeared under the 
influence of an internal inflammation, the scales, which even 
at first were but slowly formed, now ceased to be produced ; 
the edges became less and less elevated, and in a short time 
nothing remained but a round, blackish spot, the colour of 
which diminished somewhat, but did not entirely disappear. 

45 



350 SYPHILITIC ERUPTIONS. 

At the end of six weeks, the internal disease having been 
cured, the eruption again appeared, and patches were formed 
towards the centre of the former spots, which in a short time 
presented every character of the original affection. The ele- 
vated points gradually assumed the appearance of a pro- 
minent ring, but were not at first of the same colour as the 
spots themselves, presenting a copper-red colour. Some 
disks manifested themselves on parts which had previously 
been sound; their development was not preceded by a small 
spot of vivid red, as in Lepra, but by a grayish injection 
without heat, smarting, or itching. The skin which was 
not the seat of the eruption, was of a dry, unhealthy ap- 
pearance, and the patient exhaled a peculiar smell. This 
eruption may occur on all parts of the body. In the case of 
which we have spoken, it was general, and the numerous, 
black patches, separated by intervals in which the sound skin 
presented a yellowish colour, gave a most remarkable appear- 
ance to the patient. 

Former symptoms, and some analogous examples observed 
by M. Biett, with the positive characters this variety now 
presented, left no doubt as to its venereal nature. 

In the greatest number of cases, this scaly form occurs with 
characters which belong more specially to Psoriasis, and par- 
ticularly to P. guttata. The patches may be confined to a sin- 
gle region, but they are most generally to be met with at the 
same time, on the neck, back, breast, anterior part of the ab- 
domen, limbs, and face; above all, on the forehead, and some- 
times even on the scalp. Their size varies from that of a centime 
to that of a thirty sous piece. They are ordinarily isolated, 
distinct, and irregularly rounded; they are slightly elevated, 
and covered with thin, hard, whitish scales, which are but 
little adherent, and discover when they fall off, elevations 
which are not red and chapped, as in Psoriasis, but smooth, 
shining, and of a copper colour. When they resemble those 
of P. guttata, they present a character which M. Biett has 
long regarded as a pathognomonic sign; this is a small, white 
band, precisely similar to those which indicate the remains of 



SYPHILITIC ERUPTIONS. 351 

a vesicle, in the vesicular affections, and which encircles the 
base of each disk, at the point where it rises above the level 
of the skin. Sometimes, but more rarely, several of the patches 
unite and form a large copper-coloured surface, presenting here 
and there, portions of scales which are detached and slowly re- 
stored. This eruption usually commences on the arm, whence 
it extends to the breast, back, and finally to the face; it mani- 
fests itself at first by small, copper-coloured points, sometimes 
accompanied with much itching; these gradually extend, be- 
come elevated, and covered with scales, &c. 

Finally, this form may occur in some very rare cases, in the 
palm of the hands and soles of the feet, in a very remarkable 
form. It is constituted of a mass of dry, friable scales, which 
may all be removed by the slightest effort, and which disco- 
ver on their disengagement, not elevated surfaces, but a livid 
colour, and a considerable hardening of the subjacent tissue. 
This rarely exists alone; it most generally accompanies other 
syphilitic eruptions, and especially those of a scaly character. 

These different forms may often be seen on the same person 
at the same time. Thus, papulae may frequently be found 
occurring with pustules and tubercles. In general, the scaly 
form occurs unattended with any other venereal eruption, but 
like all the others, it is constantly accompanied with syphilitic 
affections of other tissues. 

Concomitant symptoms. — These different eruptions may 
be complicated with all the symptoms appertaining to Syphi- 
lis, which, as is well known, spares no tissue, or no organ, and 
we have several times seen individuals at the Hospital of St. 
Louis, who fell victims to a union of the dreadful symptoms 
with which this disease may be attended. Happily, such cases 
are rare, but at the same time, there are but few of the syphi- 
litic eruptions which are not accompanied with one or more 
symptoms of the general affection. We shall not attempt to 
describe all the alterations that Syphilis can cause in the sys- 
tem, but we think it right to briefly notice some of its symp- 
toms which form almost constant attendants on the venereal 
eruptions. 



352 SYPHILITIC ERUPTIONS. 

Among those that are met with most commonly, ulcerations 
of the throat, and especially those observable on the tonsils, 
and the mucous membrane lining the posterior part of the 
pharynx, hold the first rank; these consist, as has been observ- 
ed by Hunter, in a real loss of substance, as if a portion of the 
tonsil or mucous membrane had been removed; the edges of 
the ulcer are regular, and the centre which is deep, is covered 
with a very adherent, grayish matter. 

Next we may mention pains in the bones, periostitis, and ex- 
ostosis ; these have their seat in most instances in those parts 
where the bones are near the surface, as those of the cranium, 
the tibia, and ulna, and always begin in the most superficial 
layers. Hunter thought that the vicinity of these parts to 
the skin, and their greater exposure to the effects of cold, 
might explain why they were more obnoxious to the effects 
of Syphilis than those wnich are deeper seated. Of late years, 
these lesions have been attributed to the administration of 
mercury, but as there exists a multitude of examples of pa- 
tients who have presented these symptoms, without ever hav- 
ing taken any mercurial preparation, this opinion cannot be 
considered as valid. 

One symptom that frequently accompanies venereal erup- 
tions, and which is of great importance from its severity, is 
Iritis, so well described by Beer, and to the syphilitic nature 
of which attention has been drawn by Saunders and Wardrop, 
we shall say but a few words on it. Iritis commences with vio- 
lent pains inthe head,and dull, deep-seated pain in the eye, which 
are augmented by the action of the light; the pupil at first con- 
tracts in an uniform manner, and the movements of the iris 
gradually diminish ; the circles of this membrane experience a 
change in their colour; they assume a deeper tint, which is 
sometimes red; the free edge no longer is regular; this defor- 
mity increases till the opening may be angular; the iris swells, 
and approaches the cornea; small abscesses are formed, which 
discharge their contents into the anterior chamber, &c. Finally, 
if its progress is not speedily checked, the disease makes rapid 
progress; whilst, on the one hand, the inflammation gains the 



SYPHILITIC ERUPTIONS. 353 

capsule of the crystalline, which loses its transparency, the 
cornea, on the other, becomes opaque, and the iris appears to 
be hidden by a cloudiness. Finally, a thin layer of coagula- 
ble lymph is thrown out, which can generally be seen with a 
magnifying glass, and the iris contracts indestructible adhe- 
sions. 

Such are the general syphilitic symptoms that accompany 
most cases of venereal eruptions, which may also, however, 
be complicated with a multitude of other affections, either of 
a syphilitic character, or of a wholly different nature. Thus, 
after a certain time, ulcerations may occur in the intestinal ca- 
nal, and the patients sink under a chronic diarrhoea, often at- 
tended with very violent abdominal pains; at other times, va- 
rious symptoms of a local or general nature may ensue. 
Erysipelas of the face, for example, often accompanies a sy- 
philitic eruption of that part, in which case the latter may dis- 
appear for a short time; in all instances, it should be rather 
considered as a happy omen, than as adding to the violence of 
the disease. Finally, these affections may be attended with 
Ozena, caries of the cartilages of the nose, and schirrous indu- 
rations of the testicles; their progress is often interrupted by 
the appearance of an internal inflammation, under the influence 
of which the eruption gradually diminishes, and again appears 
as the inflamed organ regains its normal state. These erup- 
tions often occasion baldness. 

They may be complicated with diseases of the skin, of an 
entirely different nature: we have several times seen Eczema, 
Herpes, and especially Scabies, accompany syphilitic erup- 
tions of a pustular, papular, &c. character. The primary le- 
sions of these affections may also become combined; thus it is 
not unfrequent to meet syphilitic papulae, with pustules or tu- 
bercles. The scaly form usually appears alone. 

Dissection. — It is rare that death takes place from the sy- 
philitic eruptions, but it is much less so to meet with patients 
who die from the effects of a long-continued venereal erup- 
tion to whieh are superadded the violent symptoms of consti- 
tutional syphilis. In several dissections made by M. Biett, 



354 SYPHILITIC ERUPTIONS. 

he pointed to us a multitude of different alterations; Necro- 
sis, soft Exostosis, in which latter case the osseous tissue 
presents the appearance of the spongy bones, or of those which 
are partly destroyed by caries, with this difference, however, 
that the matter that fills the cells is in a semi-fluid state, and 
of a yellowish- white colour, caries, particularly of the foot, 
and fistulas. In a patient who presented all the symptoms of 
laryngeal phthisis, there were ulcerations of the mucous mem- 
brane of this organ, caries of its cartilages, and a fistulous 
opening at its anterior part. In other cases, M. Biett has 
found ulcerations of a peculiar character in the intestinal canal, 
and especially in the ileo-ccecal region. In almost all instances, 
we have observed a greater or less degree of effusion in the 
splanchnic cavities, or even in the whole of them; finally, the 
majority of the bodies of individuals who have fallen victims 
to this union of symptoms, present a livid tint, they exhale a 
peculiar and foetid odour, and putrify with great rapidity. 

Causes. — Syphilitic eruptions may manifest themselves from 
a multitude of occasional causes, as debaucheries, severe exer- 
cise, violent mental affections, &c. Sometimes, on the con- 
trary, these affections may occur without their appearance be- 
ing provoked by any appreciable proximate cause, but in all 
cases they recognise a primary exciting source, which is one 
and identical, and which we shall continue to call virus, till 
this denomination is replaced by another that is more exact, 
especially as the term venereal virus appears peculiarly appli- 
cable to a class of affections which always appear under the same 
forms, the same circumstances, and which present characters| 
only appertaining to themselves. We prefer, excepting tha 
we may pass for empirics, to admit the existence of this virus 
than to be obliged to explain the consecutive symptoms by 
sympathy whose effects may only appear at the end of ten 
twenty, or thirty years; added to which, in adopting such 
theory, the nature of the primary affection which can indue 
such consequences, would still remain to be proved. 

As to the theory which attributes the secondary symptoms 
and particularly those of the cutaneous system, to the mercur 



SYPHILITIC ERUPTIONS, 355 

administered for the cure of Syphilis, it is not better founded, 
and a person can see but few of these eruptions, not to meet, 
(we do not say sometimes, but often,) patients covered with 
them, and who have never taken a grain of mercury. 

Finally, can they be, as has been asserted, simple inflamma- 
tions of the skin, determined in most instances by a direct 
agent, or by the inflammation of some internal organ? If it 
were so, these eruptions would be met with in persons who 
have never had the venereal disease, as often as in those who 
were affected by it; how is it then, that such is never the case? 

We shall, therefore, continue to believe that the syphilitic 
eruptions, whatever may be their occasional cause; whether 
they are developed at the same time as the primary symptoms, 
or appear months or years after the infection, are always in- 
duced by the influence of a single cause, or that of a virus sui 
generis. 

In certain states they are evidently contagious; they may 
be hereditary, and it is not rare to see infants at birth cover- 
ed with syphilitic pustules, whilst in others, again, this erup- 
tion may occur a short time after birth. In other instances, 
numbers of infants may be covered with an analogous erup- 
tion, which they have contracted whilst sucking; they may 
also communicate the disease to the nurse, and Alibert cites 
the case of a woman of thirty years of age, who, having 
suckled an infant which was at first apparently healthy, but 
born of a diseased mother, was four months afterwards cover- 
ed with venereal pustules. 

In the greatest number of cases, the syphilitic eruptions ap- 
pear at uncertain times, without being dependant on any ap- 
preciable exciting cause, and whilst the patients are seemingly 
enjoying the most perfect health. As to the relation that ex- 
ists between them and the primary symptoms, experience has 
demonstrated that they may arise as well after a blennorrhagia, 
as after chancres, buboes, &c. 

Diagnosis. — The syphilitic eruptions, although presenting 
strongly marked characters in a majority of instances, are, 
nevertheless, more often mistaken than any of the others, and by 



356 SYPHILITIC ERUPTIONS. 

a singular anomaly, they are those which are the most common- 
ly believed to exist. This depends, without doubt, on the fact, 
that they may assume the form of every other eruption ; never- 
theless, they manifest themselves with well-marked symptoms, 
and moreover a certain general character is always present, 
which strikes the practised eye even before it has had time to 
recur to the details; these appearances, which it would be im- 
possible to describe, exist more particularly in the colour, in 
the manner in which the eruption occurs, and in the general 
state of the patient. 

As to the value which some pathologists have accorded to 
the success or failure of the mercurial preparations in the cure, 
as a diagnostic mark, it is evidently worse than useless, for 
although mercury is the most valuable remedy we possess for 
Syphilis, its results are liable to so many modifications, that it 
would be erroneous to base an opinion of the nature of the 
disease on its effects; besides, these eruptions present, (at least 
in a majority of cases,) characters of sufficient distinctness, to 
distinguish them from other affections of the skin, without 
there being a necessity of resorting to an uncertain and often 
inconvenient mode of discrimination. 

Syphilitic eruptions may be confounded with certain af- 
fections, according to their form or state. Those which may be 
mistaken for the Exanthematous form, are Roseola and Ur- 
ticaria for the acute varieties, and Ephelis for the chronic. 

Roseola. — This eruption differs from the grayish patches of 
the syphilitic eruption, by its rosaceous colour and the general 
symptoms that accompany it. 

Urticaria. — The patches of Urticaria, being small, de- 
veloped spontaneously, and accompanied with itching, resem- 
ble to a certain degree those of the acute exanthematous form 
of the syphilitic eruptions; but the colour is not the same: in 
Urticaria, they are either redder or whiter than the surround- 
ing skin, but never grayish, as in the syphilitic eruption; in 
the former, also, they are more prominent, the itching is far 
more violent; finally, they suddenly disappear, and again oc- 
cur after a certain lapse of time, characters which arc not to 



SYPHILITIC ERUPTIONS. 357 

be found in the latter, which moreover usually attends the pri- 
mary symptoms, and especially blennorrhagia, or at least ma- 
nifests itself immediately after their disappearance. 

Ephelis. — This differs from syphilitic spots in many par- 
ticulars. The patches of the former are irregular and larger, 
occupying a greater extent of surface, and most frequently 
occurring on the abdomen and anterior part of the breast. The 
syphilitic spots, on the contrary, are usually round, rarely 
larger than half a dollar, and not very numerous; they are 
most generally seen on the face, and especially on the forehead 
and eyebrows. Those of Ephelis are yellow, accompanied 
with itching, which in some cases is very severe, and covered 
with a furfuraceous exfoliation. Those of Syphilis are of a 
copper-red colour, sometimes even blackish; they occasion a 
very slight pruritus, and desquamate but rarely. Finally, 
they never form, like the former, confluent patches with irre- 
gular edges, covering large surfaces. 

The syphilitic spots are almost always accompanied with 
some symptoms of the general infection, and more particularly 
with Iritis. 

The Vesicular form has presented itself too seldom to our 
observation, to enable us to trace its distinctive characters in 
a positive manner. Nevertheless, the copper-coloured areola 
surrounding the base of the vesicles, their seat, number, and 
disposition, the slow progress of the inflammation, the pre- 
cursory and concomitant symptoms, are all marks on which a 
diagnosis may be established. Among the few examples that 
we have seen, there has been an ulceration of the tonsils. 

The Pustular form may be confounded with Jicne and 
Ecthyma. 

Jicne. — The pustules of Jicne, especially those which oc- 
cur on the face or forehead, may be mistaken for the psydra- 
cious pustules of the venereal affection, particularly as they may 
both present a small purulent point; but they are more promi- 
nent in Jicne, are red, and sometimes surrounded by a well- 
marked erythematous areola, whilst in the syphilitic eruption 
they present a livid hue, and their base is of a copper colour. 

46 



35S SYPHILITIC ERUPTIONS. 

The intervening skin in Acne is red, shining, unctuous, and 
studded with small, black points, whereas in the other disease 
it is corpse-like and withered. Finally, the syphilitic psydra- 
cious pustules often occasion small cicatrices, which are seldom 
induced by Acne, with the exception of A. indurata, but this 
again presents characters which are too peculiar to be mistaken. 

Ecthyma. — The phlysacious pustules of the syphilitic erup- 
tion are very analogous, in certain cases, to those of Ecthyma, 
and it is sometimes difficult to discriminate between them. 
Nevertheless, the areola that surrounds the base of the ecthy- 
moid pustules is of a purplish red, whilst it is copper-colour- 
ed in the syphilitic. The scabs in the latter are thicker, more 
adherent, sometimes almost black, and circularly furrowed. 
The ulcerations which succeed them are rounded and deep, 
with regular edges, and are always followed by a depressed 
and indelible scar. Finally, it is very rare that the patient 
does not also present other venereal symptoms. 

Tubercular form. — The eruptions that may be confound- 
ed with this form, are Lepra, some varieties of Psoriasis, 
•dene indurata, and Lupus. 

Lepra. — We have seen that syphilitic tubercles may some- 
times form perfect circles, resembling those of Lepra, but 
these are not continuous rings, as in the scaly affection, but 
are made up of isolated, smooth, prominent tubercles, of a cu- 
preous or livid colour, covered with thin, hard laminse, always 
smaller than the induration they surmount; whilst those in 
Lepra are larger, covering not only the edges, but even in 
some cases masking the whole patch. 

Psoriasis gyrata. — Syphilitic tubercles, when in the heal- 
ing stage, and when the circles only exist in part, have often 
been mistaken for Psoriasis gyrata, or even Lepra. The 
characters we have given above, as distinguishing them from 
the latter disease, are also applicable in these cases. 

Psoriasis guttata. — It is well known that syphilitic tuber- 
cles, when situated on the scrotum, have often been taken for 
this scaly affection; the former occur in this situation very 
commonly, while the latter are but seldom to be met with. But 



SYPHILITIC ERUPTIONS. 359 

it will always be easy to distinguish these round, flat, thick 
tubercles, (Pustules plates, Cullerier,) ulcerating at their 
apex, and effusing a sanious fluid of a nauseous odour, from the 
papular elevations of P. guttata, which are always dry, cover- 
ed with scales, and never become the seat of ulcerations. 

Jicne indurata. — This disease may, as we have formerly 
observed, leave on the back, which is its usual seat, circum- 
scribed indurations, sometimes of a considerable size, which 
may the more readily be taken for syphilitic tubercles from 
their being intermingled with a multitude of cicatrices, but in 
most cases the latter, when occupying this part, are hard, 
of a cupreous red, and rounded; they are often as large as a 
small hazlenut; they have not, like the circumscribed tumours 
of Jicne, succeeded to pustules; they usually become the seat 
of ulcerations, which extend to the surrounding parts, attack- 
ing the skin in various directions, and are at last covered with 
thick scabs, which leave, not small, round scars, about the size of 
a pea, but a kind of deformed cicatrix of a zigzag or spiral form. 

Lupus. — It is sometimes difficult to distinguish the forming 
tubercles of Lupus from those of Syphilis. But in Lupus 
they are reddish, soft, and small ; their summit is chapped and 
withered ; the adjacent skin is the seat of a slight cedematous 
swelling: those of the venereal affection are of a cupreous hue, 
more prominent, hard, smooth, and shining. Lupus usually 
commences on the cheeks, whilst the syphilitic tubercles ma- 
nifest themselves on the forehead or alas of the nose. Finally, 
Lupus particularly attacks scrofulous individuals of a weak 
constitution, and is most generally met with in young subjects. 
Tubercular Syphilis, which, in a majority of cases, is a conse- 
cutive symptom, on the contrary, ordinarily attacks indivi- 
duals of a certain age; it is also constantly accompanied with 
other eruptions of the same nature, and especially by symp- 
toms of the general constitutional affection. 

Papular form. — The cutaneous diseases that may be mis- 
taken for this form, are Scabies and Lichen. 

Scabies. — In some cases, the syphilitic papulae are very 
small, and slightly conical, and they may the more readily be 



360 SYPHILITIC ERUPTIONS. 

confounded with Scabies, as they have been often described 
as presenting small, transparent, serous vesicles, analogous to 
those constituting the elementary lesions of that disease; but 
independently of other and better marked characters, it will 
require but little attention to perceive that they are solid, 
firm pimples, which will always discriminate them from Sca- 
bies, which is a vesicular affection. 

Lichen. — Syphilitic lichen may be distinguished from L. 
simplex, from the circumstance that in the venereal eruption, 
the papulae are very small, slightly conical, very numerous, 
and of a deeper colour; that in some points their livid areolae 
become confluent, and give the skin the appearance of a large 
copper-coloured surface, studded with small, slightly promi- 
nent points of a more vivid tint. 

In L. simplex, the eruption is generally confined to a sin- 
gle region, and above all, to the limbs. The papular syphilitic 
eruption covers all the body, and more especially the face ; 
whilst the appearance of the papulae is almost simultaneous. 

It would be superfluous to lay down the characters that 
distinguish the papular syphilitic affections from Variola, for 
we could not have believed that these diseases could ever be 
confounded, had we not met with an example; but even in ad- 
mitting that the differences we have already mentioned in 
speaking of these diseases, were not sufficient to discriminate 
them at their commencement, still the ulterior progress of the 
eruption cannot leave a doubt. 

Finally, in some cases, the syphilitic papulae are large, flat, 
numerous, and covered with small scales, which hide the in- 
tervals between them, and impress on the eruption the aspect 
of the scaly form; but this can only exist at a certain period 
of the disease, for at the commencement, the papulae are very 
distinct, and at a later epoch, they again become evident from 
the disengagement of the scales. 

Scaly form. — This may be mistaken, as we have before 
said, for several of the scaly eruptions, but those with which 
it is most likely to be confounded, are Lepra and Psoriasis. 

Lepra. — There is one form of the syphilitic affection in 



SYPHILITIC ERUPTIONS. 361 

which the edges are prominent, and the centre depressed, 
which may be taken for Lepra, (Dartre furfurac&e arron- 
die, Al. ) as it has been described as a variety of this affection 
under the name of Lepra nigricans; but the patches are al- 
most black, as the denomination that has been given it testi- 
fies; this character alone is sufficient to distinguish it. 

Psoriasis. — Sometimes the scaly form of Syphilis presents 
the appearance of Psoriasis, and especially of P. guttata; but 
in the venereal affection, the patches have a marked coppery 
hue; they are covered with small, thin, grayish scales, much 
thinner than those of Psoriasis, and do not, like this com- 
plaint, occasion deep and painful fissures. Besides which, they 
are accompanied with a pathognomonic sign; this is a small, 
white band around the base of each spot, exactly similar to 
that which occurs in the vesicular affections. 

Such are the different eruptions, which may occasion some 
difficulty in drawing a diagnosis of the syphilitic cutaneous 
affections; this is, however much aided by concomitant symp- 
toms, as ulcerations of the throat, pains in the bones, &c. 

Finally, there are also two states of disease, which may cor- 
respond to some species of the venereal eruptions, and in 
which these latter may be confounded with cutaneous affec- 
tions of an entirely different nature; these are where there are 
thick scabs, or extensive ulcerations. 

1st. The scabs, which sometimes succeed to pustules, but 
more generally to venereal tubercles, may, as we have said, 
be taken for those of Impetigo, but in the impetiginous affec- 
tion they are yellow, and easily removed; they only appear, 
as it were, placed on the surface of the skin ; in the venereal 
eruption they are greenish, or almost black; sometimes circu- 
larly furrowed, hard, and very adherent, penetrating to some 
distance into the thickness of the dermoid tissue. 

2d. Syphilitic ulcerations may sometimes be confounded 
with those of Lupus, but the former present a union of cha- 
racters never offered by Lupus; they are deep and excavated ; 
their edges are hard, callous, regular, and surrounded by a cop- 
per-coloured areola. Those of Lupus are more superficial; 



362 SYPHILITIC ERUPTIONS. 

sometimes the surfaces which are exposed on the fall of the 
scabs, are in a state of hypertrophy ; their edges are soft and 
livid, and the adjacent skin is usually the seat of a soft, chronic 
cedematous engorgement. When they have a tendency to 
extend to the neighbouring parts, the ulcerations in Lupus do 
not present the circular, spiral, &c. forms which characterize 
the serpiginous syphilitic ulcers. 

But it is more especially when these two diseases are fixed 
on some small region of the body — the nose for instance, and 
destroy the parts, that it is difficult to discriminate between 
them. Nevertheless, independent of the characters we have 
already enumerated, it should be recollected that the ravages 
of Lupus almost always commence with the skin, whilst 
those of Syphilis, on the contrary, generally begin on the inter- 
nal parts, and particularly the bones; that the skin does not 
ulcerate for some time afterwards ; the work of destruction is 
much more rapid in the latter, and it is attended in most cases 
with other venereal symptoms. 

Prognosis. — These eruptions are not very serious of them- 
selves alone, and little is to be dreaded, without there are 
alarming symptoms of a general infection. The tubercular 
form is certainly the most severe; the scaly is very obstinate. 
As to the other varieties, they seldom last any great length of 
time. In general, the prognosis is bad, if the disease has 
lasted for some time; if the patient has had several relapses, or if 
it is complicated with venereal symptoms; finally, as we have 
observed, patients may perish from a union of horrible symp- 
toms, which cause excruciating tortures that nothing can ap- 
pease; the pulse becomes feeble, the face pale and discoloured, 
the body of a dirty and corpse-like appearance, diarrhoea, epis- 
taxis, and foetid sweats supervene, and death soon takes place. 

Treatment. — There are few diseases in which remedies 
have been at one moment more extolled, and the next abandon- 
ed, than in secondary Syphilis, and especially in the venereal 
eruptions. We shall not attempt to mention all that have 
been proposed, but shall content ourselves with indicating 
those whose use has been most generally successful. 



SYPHILITIC ERUPTIONS. 363 

As to the antiphlogistic method and emollients, which have 
of late years been vaunted as sufficient in most cases, we are 
of opinion, from a certain number of facts, that it may be ad- 
vanced; 1st. That they are often useful, and sometimes even 
indispensable as auxiliary means; 2d. That sometimes, but 
very rarely, the venereal eruptions have appeared to yield to 
their influence; 3d. That in a majority of cases they are in- 
sufficient, except in the acute exanthematous and papular forms, 
which are usually only ephemeral affections, accompanying 
primary symptoms, and disappearing with them. 

The treatment of these eruptions consists in the use of both 
internal and external remedies. 

Those of the first, which have given the most advantageous 
results in the experiments made by M. Biett, at the Hospital 
of St. Louis, are — 

1. Mercury. — The mercurial preparations are yet, without 
doubt, the most useful means of the whole materia medica, in 
treating Syphilis; if there are cases in which they evidently 
fail, they generally succeed in a most admirable manner, and 
we cannot help thinking, that a majority of the cases of failure 
have arisen from the manner in which they have been admin- 
istered. 

Thus, they should never be employed during the continu- 
ance of the acute symptoms; the doses cannot be fixed; they 
must depend on the severity of the attack, the strength of the 
patient, the action of the remedy itself, &c. Recourse may 
be had to Van Swieten's liquor, or pills of the deuto-chlo- 
ride and opium, (deuto-chloride of mercury, gr. xii. — opium, 
9i. ft. pill No. xxxvi. ) one of which is to be taken every day. 

When the patients are feeble, irritable, and there is fear of 
exciting the susceptibility of the mucous membranes, resort 
may advantageously be had to the soluble mercury of Hahne- 
man; this is peculiarly applicable in mild cases; the dose is a 
grain per day. (Soluble mercury of Hahneman, 9i. — Pulv, 
Malvse, S>L ft. pill. xxiv. ) 

But of all preparations of this kind, we have seen the most 
advantageous results from the Sir op de Larrey, given in the 
dose of one ounce, before breakfast. 



364 SYPHILITIC ERUPTIONS. 

The mercurial preparations, given with judgment, and in 
small doses, rarely occasion accidents. During their adminis- 
tration, the state of the digestive organs should be closely at- 
tended to, and if symptoms of gastric or abdominal irritation 
should arise, their use must be suspended, and not recom- 
menced till all these symptoms have disappeared. As to the 
time during which they should be used, it cannot be specified, 
as it depends on their effects, and the obstinacy of the disease. 
But we do not think that they need, (as has been recommend- 
ed,) to be continued for a month after a cure is obtained, for 
fear of a relapse. 

Sudorifics. — These remedies have often been useful, whe- 
ther employed alone, or what is better, combined with other 
means. For this purpose, a decoction of guaiacum, of rad. 
chinas, or sarsaparilla, made with half an ounce of either of 
these articles to a pint and a half of water, boiled down to a 
pint, to which may be added a scruple of Daphne mezereon, 
or cnidium; the patient may also take an ounce of the sudo- 
rific syrup in the first glass of the decoction each morning, 
fasting. 

Ptisan of Feltz. — This preparation has often succeeded 
very well, especially in cases where mercury had failed; the 
patient should take two or three glasses every day. This 
sometimes will produce a marked amelioration; in other cases, 
it is wholly inefficacious. 

Muriate of gold. — This salt has been highly praised as an 
excellent succedaneum for the mercurial preparations, but it 
is far from having produced the advantageous results that have 
been attributed to it, having failed in a majority of cases. It 
is to be administered by making frictions twice a day on the 
tongue of the patient, with a tenth of a grain at a time. 

Subcarbonate of ammonia. — Very rapid cures have some- 
times been obtained by means of the subcarbonate of ammo- 
nia, according to the plan of Professor Perylhe, particularly 
where the mercurial preparations had failed. M. Biett has 
often been successful with this remedy; he gives it at first in 
the dose of a drachm in some mucilaginous drink, and gradu- 
ally increases the dose to two or three drachms. 



SYPHILITIC ERUPTIONS. 365 

Independently of internal remedies, there are certain forms, 
certain states of the syphilitic eruptions which require the 
use of external applications. Thus, it is sometimes useful to 
hasten the resolution of the tubercles; to attain this purpose, 
great advantage has been derived from the use of several oint- 
ments, as that of the proto-nitrate of mercury, 9i. to Jss.; the 
proto-ioduret or deuto-ioduret of mercury, 9i. of the first, 
and gr. xii. of the latter to axunge, 5i. 

The patient is to be lightly anointed with these prepara- 
tions on the larger tubercles. But of all remedies of this 
kind, the most useful, and that which is followed by the most 
speedy effects, is the ointment of ioduret of sulphur, made 
by mixing gr. xx. to xxx. with an ounce of axunge; we have 
seen this remedy produce very beneficial results in a patient, 
the whole of whose back, and in fact, nearly the whole of 
whose body was seamed with cicatrices and large tubercles. 

As to lotions made with mercurial preparations, with solu- 
tions of sulphate of zinc or copper, spirituous washes, and mu- 
riatic liniments, they are generally useless, and may even be 
prejudicial. 

Finally, the syphilitic ulcers also require particular treat- 
ment; in some cases it is necessary to change the state of the 
surfaces, or to check their ravages, either by the application of 
stimulating ointments, as those of the deuto-oxide, the deuto- 
ioduret, or cyanuret of mercury. Sometimes they must be 
attacked more energetically, and slight cauterizations by 
means of the acid nitrate of mercury have proved useful; 
finally, we have several times seen M. Biett calm the violent 
pain these ulcerations often occasion, by applying small dos- 
sils of lint, spread with the hydrocyanic cerate, (hydrocyanic 
acid, gtt. xx. — Cerat. simp. ^ij. 

Such are the means which must be employed in a majority 
of cases of the syphilitic eruptions; they may all be power- 
fully aided by the use of baths; thus, douches of vapour used 
for twelve or fifteen minutes on the affected parts are very 
effectual in hastening the resolution of the tubercles; alkaline 
baths are proper in almost all cases of syphilitic pustules. Va= 

47 



366 SYPHILITIC ERUPTIONS. 

pour baths greatly contribute to the cure of the scaly form. 
Finally, the employment of baths, in some instances, will suf- 
fice to cure some of these eruptions: fumigations of cinnabar, 
especially when administered locally with M. Bietr's appara- 
tus, often induce the resolution, and even the complete remo- 
val of tubercles which so frequently occur on the scrotum and 
verge of the anus. 

As to the baths of solution of corrosive sublimate, with 
which experiments have been made of late years, the results 
have not as yet been entirely satisfactory, and we think that 
at best they can be but uncertain in their effects. In most 
cases, this salt is dissolved in solutions of the alkalies, and 
hence modifications have arisen which have not been suffici- 
entlv examined; the solution is certainly not complete, and 
hence how are we to judge of its effects a priori? But in sup- 
posing that the deuto-chloride can be completely dissolved, 
still its action is very variable, not only on different indivi- 
duals, but also on the same person. It is well known how 
much the energy of the absorbents depends on the physiolo- 
gical and pathological state of the skin. In certain cases, this 
poisonous salt may be absorbed in considerable quantities, 
and hence exercise a fatal action on the economy. At other 
times, no absorption may take place, and not a single atom 
enter the system. We must therefore wait for more exact 
experiments, before deciding on this plan of treatment. 

In many cases, these eruptions resist all the means we have 
pointed out, and become complicated with alarming symptoms 
of a general affection. In these instances, we have seen, (a 
plan which has long been praised, and whose good effects every 
day's experience confirms,) opium given, at first in the dose 
of half a grain a-day, and augmenting it every three or four 
days, in the same proportion, produce the most beneficial ef- 
fects. It may be carried, (the aqueous extract of opium.) to 
four grains, or even more: it is not rare, under the use of this 
invaluable medicine, to see really alarming symptoms, which 
had resisted a multitude of other preparations, entirely dis- 
appear. 



SYPHILITIC ERUPTIONS. 367 

Finally, it may happen that when the best-directed plans of 
treatment have entirely failed, to see these eruptions cured by 
empirical preparations; thus M. Biett has often obtained re- 
markable success with the decoction of Arnoult and that of 
Zittmann. Full details on the use of this latter preparation, 
may be seen in the last edition of Lagneau's excellent treatise. 
Sometimes, however, after the employment of it, a profuse 
diarrhoea may arise, which forces us to abandon or suspend its 
use, but in the generality of cases we have observed, this pre- 
paration agrees with the patients, and has often been followed 
by unlooked for success. 

By the aid of these various means, we are usually enabled 
to successfully combat the venereal eruptions and their con- 
comitant symptoms; some of these latter, however, require 
particular treatment. 

In ulcerations of the throat and soft palate, fyc. it is of- 
ten very advantageous to have recourse to mild solutions of 
corrosive sublimate, as gargles; a few drops of laudanum should 
always be added. 

In Iritis, which is so frequent a complication of the syphi- 
litic diseases, general bleedings are sometimes requisite, or 
leeches behind the ears; but the plan so highly spoken of by 
the English practitioners, and which we have so often seen 
employed with success, of calomel in large doses, eight, ten, 
or twelve grains, for instance, is certainly the best in these 
circumstances. 

When these eruptions occur in a child that is not yet wean- 
ed, the mother or nurse must be put under medical treatment, 
as for instance, giving her the liquor of Van Swieten, or what 
is better, causing her to make frictions on her legs and thighs, 
alternately, with ung. Neapol. and camphor, (ung. NeapoL 
§ij. camphor 5ss. : this is for twenty-four applications.) 

Finally, if the mother or nurse are too feeble to follow this 
treatment, the infant must use the milk of a goat, on whom 
these applications are to be made. 

We have seen these different methods used at the Hospital 
of St, Louis, with the most complete success. 



( 368 ) 



ORDER XII. 

PURPURA. 

BY this term is meant an eruption characterized by patches, 
sometimes of a vivid red, sometimes of a livid hue, the ex- 
tent of which is sometimes only a line, and at others of seve- 
ral inches, preserving their colour under pressure, usually to 
be found on the skin only, but also existing in some cases on 
the mucous membranes, in which case there are often hsemor- 
rhagies. 

The name of Purpura, used by some authors of the seven- 
teenth century to designate some forms of exanthematous erup- 
tions, has been applied by Willan exclusively to the malady 
whose characters we have just enumerated. The denomina- 
tions of Hemorroea petechialis, Ecchymome, Hemacelinose, 
fyc. proposed by Adair, Franck, and Perquin, may be more 
exact and harmonious to the ear; but we think that names 
adopted by pathologists who have devoted themselves to a sub- 
ject, and who have thence acquired a certain authority, should 
always be preferred. We have not thought it right to follow 
the example of Willan, in arranging this disease with the Ex- 
anthemata; it has appeared to us that if it did agree with 
this order in some points, still that it differed in many impor- 
tant characters, and especially in the absence of all fever. In 
the Exanthemata the patches are numerous, red, and produced 
by inflammation and engorgement of the cutaneous capillaries; 
in Purpura there is no inflammation nor injection of the ves- 
sels, it is constituted of an effusion of blood in the superficial 
layers of the dermoid tissue. We have therefore placed it 
among those diseases which cannot be arranged in any of the 
regular orders. 

The red patches which form one of the characters of this 
genus, are frequently termed Petechias by some authors. They 



PURPURA.. 369 

have generally been considered by pathologists as fatal symp- 
toms, and as accompanying fevers of a malignant character. 
Thus they are often mentioned by writers on the Plague, and 
latterly by those who have treated of Typhus. They have 
been seen as complications of some of the eruptive diseases, 
and in a majority of instances may be deemed a fatal symptom, 
and indicating great disorder of the system. The name of 
Petechia thus carrying with it the idea of a severe symptom, 
we shall not use it, except as designating those cases where the 
spots are symptomatic of a more serious and general disease. 

Willan has divided the genus Purpura into the following 
species: 1st. Purpura simplex; 2d. Purpura hemorrhagica; 
3d. Purpura urticans; 4th. Purpura senilis; 5th. Purpura 
contagiosa. 

Purpura simplex. — In this species, designated by some 
authors under the name of Petechise sine febre, the patches are 
of a clear, red colour, and of no great extent. The eruption 
manifests itself in a few hours, generally during the night, 
and in a successive manner, so that, although not numerous at 
first, the patches augment in a marked manner in a short time. 
The parts principally affected are the limbs, particularly the 
thighs and legs, the arms and shoulders become implicated at 
a later period, but almost always with less intensity. 

The eruptions generally succeed each other in rapid succes- 
sion, so that whilst some spots are fading and disappearing, 
others again are commencing and increasing. At other times 
these successive eruptions are not continuous; thus M. Biett 
has seen in a nurse in one of his wards, aged about thirty-eight 
to forty, and of a robust constitution, these eruptions succeed 
each other at short intervals for more than two years, without 
her general health suffering in any great degree. She is, how- 
ever, subject to dysmenorrhea, which always occasions a great 
degree of plethora. The duration of P. simplex may vary 
from three or four weeks to eighteen months or two years ; 
that of the individual patches is about six or eight days, but 
may sometimes be prolonged to two weeks. 

In most cases this variety is preceded by a little uneasiness, 



370 PURPURA. 

anorexia, some head-ache and lassitude, but without any ap- 
preciable trouble in the circulatory functions. In other indi- 
viduals again there are no precursory symptoms. 

During the first days the spots are of a vivid red, especially 
in young persons, but are of a deeper colour in elderly per- 
sons ; they are distinct and irregularly rounded. After some 
days they acquire a deeper, more livid hue, then become yel- 
lowish, and gradually disappear. 

Causes. — P. simplex may occur at every period of life, 
but shows itself most frequently in youth and adolescence, 
rarely in middle-aged persons, and very seldom in the elderly. 
Sometimes it attacks vigorous, sanguine individuals, whose ar- 
terial system possesses great energy, and whose tissues have a 
remarkable firmness; at other times it manifests itself in feeble 
persons, whose constitutions have been debilitated by a va- 
riety of causes. In general, those having white, soft, moist 
skins, are more subject to it than those in whom this membrane 
is brown, dry, and bilious. 

It appears most frequently in the summer, in dry days, than 
in winter or autumn. We have sometimes seen, during the 
heats of July and August, many persons affected with differ- 
ent degrees of eruption, present themselves at the Hospital of 
St. Louis. Food and the mental affections may also influence 
its development, but it is difficult to appreciate their action in 
a definite manner. 

Diagnosis. — If the patches of P. simplex be examined with 
attention, they can never be confounded with either of the 
other varieties of this affection, or the various forms of the 
Exanthemata. The fundamental character is the persistence 
of the colour under the strongest pressure; a character which 
never exists in the Exanthemata, or only appears in the 
complications we have noticed; it is therefore useless to dwell 
on the marked differences of these diseases. Is it necessary to 
mention that it is sometimes possible to confound the dark red 
spots of P. simjilex with the bites of insects, and particularly 
with those of fleas? But it is always easy to distinguish a cen- 
tral spot of deeper colour, when the puncture has taken place; 
the rest of the spot is a lighter tint. 



PURPURA. 371 

Prognosis. — P. simplex can never be considered as a fatal 
disease, even where it exists in feeble and shattered constitu- 
tions; it almost always yields to hygienic means or appropri- 
ate remedies. 

Treatment. — It may be readily supposed that the treat- 
ment of a disease which may occur under such different cir- 
cumstances, must require numerous modifications. 

If the eruption occurs in a vigorous, young, and sanguine 
individual, induced by hard labour or the abuse of stimulants, 
blood-letting is the best remedy, aided by the use of a few 
cool baths, rest, and a low diet. 

If, on the contrary, it takes place in feeble, enervated per- 
sons, whose tissues are relaxed, or who are debilitated by ex- 
cesses, privations, &c. blood-letting, instead of being useful, 
only adds to the general debility; in these cases recourse must 
be had to a strengthening diet, generous wine, bitters, ferru- 
ginous preparations, stimulating frictions, alcoholic fumiga- 
tions with Darcet's apparatus, taking care never to raise the 
temperature beyond 40° to 44°, Reaumur; (122° to 131° Fahr.) 
M. Biett has used this plan with great advantage in several 
cases. 

Purpura hsemorrhagica, (Morbus maculosus hemorrha- 
gica, Werlhlof. ) — This species is characterized by more nu- 
merous spots of a deeper colour, among which may be seen 
large, irregular, livid patches, and also some resembling recent 
bruises. They first manifest themselves on the lower extremi- 
ties, then on the arms and body ; the hands are rarely attack- 
ed; the same may be said as regards the face, though we have 
several times seen small spots of it around the eyelids. The 
parts on which they appear do not become elevated. Never- 
theless, as has been observed by Bateman, to whom we owe 
an excellent description of this disease, the cuticle has been 
seen raised into a sort of vesicles or bullae filled with blood. 
M. Biett has seen a case of this kind at the Hospital of St. 
Louis, and several cases of it are recorded by Reil and Willan. 
Spots of the same kind may occur on the mucous membranes, 
especially on the gastro-pulmonary; these tissues being thin 



372 PURPURA. 

and delicate are easily torn, causing hsemorrhagies to a greater 
or less extent from the mouth, nostrils, urethra, rectum, or 
vagina. 

These effusions of blood, according to Bateman, may be 
very copious, and speedily become fatal, but in general they 
are moderate, return at intervals, and cease spontaneously. 
Sometimes they are periodical, whilst in other cases they re- 
turn at irregular intervals. Finally, the flow of blood may be 
almost continual, but in small quantities. These haemorrhages 
are usually occasioned by large ecchymoses on the gums, in- 
ternal part of the cheeks, tongue, and even in the bronchia, 
stomach, intestines, uterus and bladder. These effusions may 
also take place in the other tissues. We have seen a case where 
the blood had accumulated under the arachnoid. 

The P. hemorrhagica is often preceded by lassitude of the 
limbs, vague pains, a general uneasiness, with inability for 
exertion; at other times it may be developed without any pre- 
cursory symptoms, or apparent change in the state of the pa- 
tient's health. In a case related by M. Biett in his lectures, a 
robust young man went to bed in perfect health after his accus- 
tomed labour, and on the succeeding day his skin was cover- 
ed with ecchymoses, and the blood issued in quantities from 
his mouth and nostrils. In general, P. hemorrhagica is ac- 
companied with a state of depression and languor, the pulse is 
sometimes feeble and easily compressible, and at others is firm 
and resisting. In some cases it is attended with slight febrile 
symptoms, having exacerbations. In some patients the appear- 
anceof the spots ispreceded by uneasiness atthe prsecordia, pains 
in the loins and abdomen, whilst in others it is announced by 
a dry and frequent cough. The state of the digestive organs 
also presents numerous variations; some individuals experience 
a feeling of tension at the hypochondrium or epigastrium, and 
are alternately troubled with constipation or looseness. In 
most cases, however, the digestive organs remain in a normal 
state. If the symptoms are aggravated or prolonged, the pa- 
tients become emaciated, and the skin presents a tumid appear- 
ance, particularly in the lower extremities and the face, if a 



PURPURA. 373 

horizontal position has been maintained for any length of 
time. 

What we have said as to the duration of P. simplex, also 
applies to P. hemorrhagica; that is, it presents great varia- 
tions. Sometimes the disease terminates in a few days; at 
other times it may be prolonged several months, or according 
to Bateman, several years. 

When the eruption terminates fatally, it is almost always by 
a considerable haemorrhage taking place in some important 
organ. Thus, we have seen patients suddenly expire from a 
copious haemoptysis; in others, again, haematemesis or intesti- 
nal haemorrhage have supervened with great violence; in some 
rare cases, death has arisen from uterine haemorrhagies, either 
following labour, or at the critical period. In a case publish- 
ed by our colleague, M. Gustave Monod, death was occasion- 
ed by an effusion taking place over the glottis, and thus in- 
terrupting respiration. 

Causes. — The causes of P. hemorrhagica are like those 
of many other diseases, enveloped in much obscurity. It 
often occurs under diametrically opposite circumstances. Thus, 
it may appear in persons who enjoy all the advantages of for- 
tune and luxury, and it may also attack those who are exposed 
to all kind of privations, or are subjected to violent and de- 
pressing mental affections. 

In some cases, this disease supervenes on another, particu- 
larly on the exanthematous affections; it may also occur in 
women after delivery. This diversity in the etiology of Pur- 
pura, as is judiciously remarked by Bateman, involves the 
true nature of the affection in some degree of obscurity. 

In general, P. hemorrhagica takes place most frequently 
in women, or children before the age of puberty. At the 
Hospital of St. Louis, however, the numbers of both sexes 
affected with the disease, were about equal. Some persons 
appear to be strongly predisposed to it; such was the case of a 
young man related by Bateman, in whom a very slight pres- 
sure on the skin would occasion ecchymoses, without his 

48 



374 PURPURA. 

health appearing to suffer in the slightest degree. He was 
suddenly carried off by a pulmonary haemorrhage. 

The immediate cause of this disease has been attributed to a 
want of tone in the extremities of the vessels, thus permitting 
the blood to escape on the cutaneous surface or mucous system. 
This feebleness of the vascular system maybe admitted as likely 
to occur in persons who are debilitated from any cause; but it is 
difficult, if not impossible, to explain how it can take place in a 
few hours in strong and vigorous individuals, and who are 
apparently enjoying the most perfect health. Besides, it 
should be recollected that if this want of resistance in the so- 
lids really exists, there is also, in a majority of cases, a pecu- 
liar alteration of the blood, which favours its passage through 
the relaxed coats of the vascular extremities. In many per- 
sons who were examined after death, at the Hospital of St. 
Louis, the blood was found in a state of remarkable fluidity, 
even in the tissues where it had been effused in considerable 
quantities. 

Some English pathologists have thought that the purpurine 
spots must necessarily be preceded by a congestion in the 
venous system; this opinion may perhaps be correct. M. 
Biett observed in a patient in whom this disease had suddenly 
developed itself, the tongue of double its natural size, and 
having a deep blue colour, evidently depending on a conges- 
tion of venous blood. The lips presented the same hue, as 
did also several parts of the face. 

Dissection. — On the bodies of individuals who have died 
from P. hemorrhagica, there are generally to be seen purple 
spots and ecchymoses, formed by effusions of blood in the cu- 
taneous and subcutaneous tissues; the first are superficial, and 
only appear to occupy the surface; the others are more deeply 
situated. The blood was easily removed on washing the 
parts, but we could not discover vascular ramifications com- 
municating with these effusions, and the researches made by 
M. Fourneaux, have had the same result. 

The mucous membranes of the mouth and pharynx some- 
times presented purpurine spots. That of the stomach and in- 



PURPURA. 375 

testines was often studded with them. Similar patches were 
also discoverable, but less frequently, on the peritoneum and 
pleura; they were even seen on the pericardium, the surface 
of the heart, and in the ventricles there was also in some in- 
stances an aneurismal state. 

The lungs were sometimes sound, but generally sanguine 
congestions of different degrees constituting true pulmonary 
apoplexies were to be seen. Finally, in some cases, partial 
effusions were met with in the muscles, in the viscera, and in 
the sub-serous tissue, &c. 

In some cases, every organ of the body appeared to be the 
seat of these bloody discharges. 

In the case related by Monod, already 'alluded to, and 
which we ourselves saw at the Hospital of St. Louis, the brain, 
the lungs, the liver, the kidneys, spleen, and in fact, all the 
organs, whether parenchymatous or membranous, offered dif- 
ferent degrees of sanguineous effusion. Such cases are rare, 
but an analogous one, perhaps still more remarkable by 
the number of parts affected, has been published by M. Ro- 
bert. 

Diagnosis. — There are certain cases of syphilitic Ecthy- 
ma of the lower extremities, in which the confluent pustules 
leave large patches of a reddish-purple colour, or even small 
spots, which resemble, and at the first glance, may be mista- 
ken for Purpura hemorrhagica, but the pre-existence of 
pustules, and the course of the disease, will dissipate all kind 
of doubt. 

As to ecchymoses from external violence, nothing but the 
very fact of the injury having been received, can distinguish 
them from those which have arisen spontaneously. But in these 
cases, the absence of haemorrhage is a characteristic mark. P. 
hemorrhagica, characterized by the presence of purple spots 
and ecchymoses, accompanied with different degrees of haemor- 
rhage from the mucous surfaces, can scarcely be confound- 
ed with any other disease. In epistaxis, haemoptysis, &c. there 
are never any spots on the skin. But this disease may be 
mistaken in cases where all its characters are evident. In a 



376 PURPURA. 

girl of twelve years of age, to whom M. Biett was called, this 
malady had been taken for a gangrene, which it was supposed 
would be promptly fatal. Yet her skin was covered with 
spots and ecchymoses, and the haemorrhagies were frequent. 
She was restored to health in a few weeks under the care of 
this practitioner. The surgeon who committed the error, has 
since published an account of the case, and has attributed to 
himself all the honour, when he had been grossly mistaken in 
the diagnosis, and had nothing to do with the cure. 

Scurvy, when accompanied with spontaneous ecchymoses 
and haemorrhagies, appears to be identical with the disease 
under consideration. The differences laid down by authors 
are — 1st. That the Scurvy is only developed under the influ- 
ence of a debilitating diet, fatigue, exposure to cold and damp, 
&c. whilst the Purpura may manifest itself in individuals 
who are not subjected to any of these causes. 2d. That Scurvy 
yields to the employment of tonics and fresh vegetables, 
whilst P. hemorrhagica often resists these means. But in 
advancing that Scurvy and P. hemorrhagica are two distinct 
diseases, the diagnosis must be based on better marked differ- 
ences than those just cited. In fact, the causes to which the 
appearance of Scurvy has been attributed, are those which of- 
ten occasion Purpura, and if the tonic treatment does not 
always succeed in the latter, it is well known that it is not 
always followed by success in the former. But in admitting 
the complete identity between these two diseases, it is at the 
same time very difficult to explain why the latter should ma- 
nifest itself in persons placed in opposite conditions to those 
in whom the Scurvy is developed. Perhaps in these indivi- 
duals, too succulent a diet, and want of exercise, produces a 
disorder in the circulation and other functions, somewhat ana- 
logous to that resulting from direct debilitating causes; or 
they may be referred to a peculiar idiosyncracy. But in as- 
similating these two diseases, we only intend to include those 
scorbutic affections accompanied with ecchymoses and spon- 
taneous haemorrhage, for, as has been observed with much jus- 
tice in the thesis of our former colleague. Dr. Fourneaux, 



PURPURA, 377 

of Caen, the name of Scurvy has been given to diseases of 
wholly different natures, of which the following words of Wil- 
lis are a proof: " Si accidens quoddam inusitatem nee prius 
auditum in corpore humano eveniat, cum ad aliud certum 
morbi genus referri nequit, sinedubio statim illud scorbuticum 
pronuntiamus." (Willis, De Scorbuto. Cap. I. p. 14.) 

The diagnosis of the concomitant affections often presents 
difficulties and demands much attention. Epigastric and ab- 
dominal pains, with nausea, may often lead to the belief of 
the existence of gastro-intestinal inflammation, if the slowness 
of the pulse, and the want of heat in the skin, did not indicate 
that it was rather to a congestion than to an inflammation that 
we must attribute these symptoms. 

Prognosis, — The prognosis of P. hemorrhagica should 
always be established with great caution, for this affection, 
though oftentimes very slight at the commencement, may ra- 
pidly become severe or even mortal. There is, in fact, nothing 
on which the physician can certainly draw a conclusion as to 
its termination. Nevertheless, the age, constitution of the 
patient, duration of the disease, and frequency of the haemor- 
rhage, must always influence our judgment; this also applies 
to the concomitant affections. The quantity of blood lost by 
the patient should always be taken into account. But this dis- 
ease is generally serious and often mortal. 

Treatment. — The treatment is environed with many diffi- 
culties, and the most opposite plans of cure have been proposed. 
The general debility with which it is accompanied, and its 
asthenic state, have appeared to exclusively indicate the use of 
active tonics, nourishing diet, wine, and of all means capable 
of restoring and strengthening the constitution, but in many 
cases their employment far from producing the expected ame- 
lioration, has, on the contrary, augmented the evil. This plan 
of cure, employed with caution, conjointly with the proper 
hygienic measures, is only useful in children, elderly persons, 
and in those who have been enfeebled by privations, &c. The 
tonics to be employed, are decoction of cinchona, extract of 
rhatany, in the dose of a scruple to a drachm per day, generous 



378 PURPURA. 

wine, the mineral acids, and a nourishing diet suited to the 
age and habits of the patient. When, on the contrary, the 
disease is developed in adults, in young persons of good con- 
stitutions, whose habits are not sedentary, who live well, and 
inhabit healthy situations, this treatment is never successful. 
It should never be employed in robust or plethoric persons. 
Finally, whatever may be the state of the patient, his age, con- 
stitution, existence of certain symptoms, as epigastric pains 
with tension of this part and of the abdomen, constipation, 
cholera, pain at the praecordia, hardness of the pulse, either 
with or without acceleration, all contraindicate the use of 
tonics. 

It is not on mere theory or reasoning that many authors, as 
Bateman, Harty, Duncan, Buxton, and Plumbe, have based 
their opinion as to the inutility and even danger of tonic re- 
medies, but on positive facts, and it consequently merits strict 
attention; it also agrees with the physiological doctrines at 
present so prevalent. The observations of M. Biett all tend 
to the same conclusion. 

Can the same be said of the use of purgatives, as affording 
advantageous results? According to the above-cited patho- 
logists, the epigastric pains, and those felt in the hypochon- 
dria, or any other region of the abdomen, either with or with- 
out tension of these parts; the derangements observed in the 
digestive functions, and the complete absence of all fever, all 
prove that much reliance ought to be placed on them. Dis- 
section confirms this opinion. There is found, in fact, evi- 
dent traces of congestion and effusion, but not of inflammation, 
in the intestines. Those purgatives which have been the most 
highly praised are jalap, castor oil, calomel, and spirit of tur- 
pentine in large doses. 

Bleeding is a means which has often been employed in 
the treatment of P. hxmorrhagica, and its use appears in fact 
to be often indicated, if not by the existence of inflammation 
in the viscera, at least from the congestion, besides which its 
employment diminishes any difficulty in the respiration. Never- 
theless, it must be stated from positive facts, that blood-letting, 



PURPURA. 379 

either general or local, should always be employed with caution, 
as well from the additional feebleness it occasions, as from the 
difficulty of arresting the flow of blood. The only cases in 
which it should be used is where the disease is developed in 
strong and robust adults, in whom evident signs of inflamma- 
tion are present, such as violent local pains, acceleration of 
the pulse, heat of skin, &c. and when the morbid hsemorrhagies 
are slight. 

M. Biett has found that the most advantageous treatment 
consisted in the use of acidulated drinks and laxatives; in some 
cases he has used with advantage the extract of rhatany mix- 
ed with ice. This method is also praised by a skilful practi- 
tioner of Lyons, Dr. Brachet, to whom we are indebted for 
an excellent memoir on the Morbus maculosus. 

The haemorrhagies that take place by the natural passages, 
require the use of lotions or injections of iced water, either 
acidulated or rendered styptic, and, if they should continue, 
the use of the tampon. In these circumstances, the latter 
should be used with great caution, as the blood has not a 
tendency to coagulate. 

Ablutions with cold water, over the whole body, have some- 
times appeared useful, and perhaps cold shower-baths might 
be attended with advantageous results. 

Compresses moistened with cold vinegar, or the solution of 
the chloride of lime, or even weak alcohol, may be applied to 
good effect on the spots and ecchymoses. 

As to the pains that exist in different parts of the body, 
they are to be combated by opiates, emollient lotions, cata- 
plasms, or bladders of warm milk. If there should be inflam- 
mation in the ecchymosed spots, recourse must be had to sooth- 
ing applications. 

The hygienic means consist in a free circulation of air, living 
in a high and dry situation, following a regulated diet composed 
of animal jellies, a small quantity of roasted white meats, and 
generous wine, always taken well iced. Finally, during the 
convalescence tonics may be employed, as the ferruginous 
preparations. 



380 PURPURA. 

Of the other species admitted by Willan, one, the P. urti- 
cans, is founded on the fact that in some cases the round spots 
instead of remaining on a level with the surrounding skin, 
slowly swell ; but this slight tumefaction disappears in the 
course of one or two days, and the surfaces become level, 
whilst at the same time, the violet-red colour becomes deeper. 
It is only an occasional occurrence, and cannot prevent this 
variety from being included as a P. simplex or P. hemor- 
rhagica. The other, P. senilis, presents no other peculiarity, 
except its having been observed in individuals advanced in 
age, and its symptoms, its march, and the curative means it 
demands, are all indicated in our former descriptions. The 
third, P. contagiosa, is apparently the petechial eruption which 
sometimes accompanies typhoid fevers, and upon which we 
have said all that is requisite. 



( 381 ) 

ORDER XIII. 

ELEPHANTIASIS OF THE ARABS. 

Lepre tuberculeuse HSphantine, Al. Barbadoes leg. 

AS we have already said, two different diseases have been 
known under the name of Elephantiasis, between which 
there is no resemblance except their name. The one, Ele- 
phantiasis grzecorum, is characterized by tubercles of greater 
or less prominence, and of different sizes, accompanied with 
a yellow tint of skin, loss of hair, diminution of sensibility, 
&c; the other, which was described at a later period by 
the Arabian physicians, and of which we shall now treat, 
is constituted of a hard swelling of some extent of the subcu- 
taneous cellular tissue, with a greater or less deformity of the 
diseased parts. 

Elephantiasis of the Arabs, a long time since indicated by 
Rhazes, and more particularly described in the eighteenth 
century by Town, Hillary, and Hendy, under the name of 
the Barbadoes leg, is detailed in all its forms and conditions 
in an excellent monograph published on this subject in 1806, 
by Alard, who has there grouped a multitude of diseases known 
under different appellations, and which he considers as having 
a complete analogy with this affection; as for instance, the 
Hydrocele and Pedartrocace of Kaempfer, the Senky, or colic 
of Japan, the fleshy Hernias of Prosper Alpinus, the Egyp- 
tian sarcocele of Larrey, and the Erysipelatous fever of 
Sennert and Hoffman. As this disease is not common, and 
has only presented itself a few times to our observation, and 
finally, as the work of Alard gives a complete history of it, 
we shall make use of his descriptions in several places. 

Elephantiasis of the Arabs is characterized by a tumefac- 
tion of the skin and subjacent cellular and adipose tissues; this 

49 



382 ELEPHANTIASIS OT THE ARABS. 

is hard, permanent, and accompanied by deformity of the 
parts on which it is situated, sometimes to such a degree as 
fully to justify its name of Elephantiasis. 

It may appear on all parts of the body; it has been seen on 
the face, neck, breast, parietes of the abdomen, scrotum, pe- 
nis, verge of the anus, and labia pudendi, but its usual seat 
is on the limbs, particularly the lower extremities; it some- 
times gives them so extraordinary an appearance and increase 
of bulk as is repulsive in the extreme. Elephantiasis rarely 
attacks both legs at the same time. 

It is generally of long continuance, or may even last during 
the lifetime of the patient; sometimes it disappears, and re- 
turns after a lapse of time on the same spot; at other times it 
may entirely leave its original seat and appear in another. 
Although it is somewhat active at its commencement, it fol- 
lows a chronic march, and even under the most favourable 
circumstances usually lasts for several months. 

Symptoms. — Under the name of Elephantiasis of the 
Arabs, several diseases have been described which Alard does 
not consider as such, or at least in which the commencement 
is not always characterized by acute inflammation of the lym- 
phatic vessels, and the phenomena of which, although very 
analogous, are constituted by a hard swelling of the subcuta- 
neous cellular tissue, as if hypertrophy had supervened on a 
chronic inflammation, or from some other cause, in which, 
perhaps, the lymphatic system might be somewhat implicat- 
ed; we saw two cases of this kind in the Hospital of St. Louis, 
who were both suffering under a swelling of the legs which 
presented all the characters of Elephantiasis. In one, the 
subcutaneous cellular tissue had become the seat of a chronic 
inflammation, with swelling and hardness of the limb; in the 
other, a seaman, and habituated to having his legs constantly- 
wet, there was observed, after the cicatrization of a varicose 
ulcer, hypertrophy and hardening of the skin and subjacent 
cellular tissue, which arose to such a height, that the leg and 
almost all the thigh were doubled in size, hard, tense, and 
shining, though little, if at all painful. In the last case the dis- 



ELEPHANTIASIS OF THE ARABS. 383 

ease was accompanied with a swelling of the inguinal glands, 
but this was entirely consecutive, and the lymphatic system 
presented no symptoms of acute inflammation at the commence- 
ment. This was also the case, in a patient observed by Dr. 
Bouillaud ; this was a woman in whom the lower extremities 
were engorged from the obliteration of the crural veins, and 
even of the vena cava itself; they became extremely hard, 
very much swelled, and resembled the legs of an elephant. 

In a majority of instances, however, this disease presents 
the symptoms so well described by Alard, and perhaps such 
are the only true cases of it. 

In general this affection manifests itself in a sudden and un- 
expected manner, without having been preceded by any pre- 
monitory symptoms; the patient experiences a violent pain, 
which gradually extends itself along the course of the lympha- 
tic vessels; in a short time a kind of hard, tense chord, here 
and there interrupted by nodosities, may be felt. This chord 
is often exceedingly painful when touched, and usually termi- 
nates at some of the large glands, as those of the groin or 
axilla, which become enlarged. 

When the disease, (as is commonly the case,) attacks the 
limbs, the affected part becomes the seat of an erysipelatous 
inflammation, the cellular tissue itself inflames, and consider- 
able swelling ensues. These symptoms are attended with ge- 
neral phenomena; fever takes place; there is much thirst, nau- 
sea, and vomiting, accompanying a prolonged chill, to which 
a violent heat of skin or even copious sweats succeed; some- 
times the brain is sympathetically affected, and the patient is 
seized with delirium. All these symptoms, with the except 
tion of a slight swelling, entirely cease, and again return at 
uncertain intervals. At the end of every exacerbation the ery- 
sipelatous redness which occurs on the course of the lympha- 
tic vessels disappears; but each time the swelling increases 
and lasts after all the other symptoms have ceased, so that at 
the end of a certain period, of some months for instance, the af- 
fected parts present an engorgement, which, although it is at 
first soft, gradually becomes so hard as to resist the impres- 



384 ELEPHANTIASIS OF THE ARABS. 

sion of the finger. The disease thus goes on for some time ; 
at last it stops, and may remain stationary during several 
years. It now manifests all those characters which constitute 
it, and gives to the parts in which it is situated, a deformed 
and frightful appearance. Sometimes there is a uniform swel- 
ling of the arm or leg which not only disguises all the promi- 
nences of the limb, but may even cover part of the hand or 
foot, falling over them in folds; these parts seem as if they 
were in a state of atrophy ; at other times the tumour is un- 
equal, the swellings are deformed, and separated from each 
other by deep fissures, giving an extraordinary and hideous 
aspect to the limb. Again, the disease has a tendency to at- 
tack fresh surfaces, and although at first developed on the fore- 
arm or leg, it gradually extends over the whole limb. The 
cellular tissue continues to alter, and is at last converted into 
a mishapen, fungous mass. Under other circumstances, how- 
ever, the disease is confined to one seat, and may even be but 
little developed; in all cases, the palms of the hands, and soles 
of the feet are free from the swelling, whilst the remainder of 
these parts is much tumefied; this arises from the cellular tis- 
sue being of a closer and firmer texture in these spots. 

The skin, which, as we have stated, is not at first affected, 
may now assume different appearances; thus, it may remain 
entirely sound, and only present a whiter colour, and great 
firmness; at other times, the subcutaneous veins, much dis- 
tended and enlarged, traverse it in all directions, causing a 
multitude of varicose tumours, which give it a violet colour; 
but this membrane may also undergo real alterations. It often 
becomes the seat of an erysipelatous, or even vesicular inflam- 
mation; in the latter, a slight effusion of lymph occurs, follow- 
ed by small, thin, soft, yellow scales; it may, on other occa- 
sions, gradually increase in roughness, and present scales si- 
milar to those of Ichthyosis, or even become studded with 
small, soft, fungous vegetations; and finally, under some cir- 
cumstances, it is divided by fissures, cracks, and ulcerations, 
which are afterwards covered by thick, yellow scabs. 

The lymphatic glands, after having remained hard and scir- 



ELEPHANTIASIS OF THE ARABS. 385 

rhous, may sometimes suppurate, or be struck with gangrene. 
Indolent abscesses, which give rise to deep, foetid, copious 
suppurations, occur at this time throughout the enormously 
distended limb. 

We do not know precisely, whether the swellings of the 
neck, breast, abdomen, &c. admitted by Alard, are really true 
cases of Elephantiasis; these instances are exceedingly rare, 
and as we should be obliged to point out all the distinctions 
that exist between the different diseases which have been de- 
scribed as Elephantiasis, we think it better to refer our rea- 
ders to Alard's work, and to confine ourselves to the most 
common form of the disease, that which attacks the limbs. 
Nevertheless, the penis is a very frequent seat of this affec- 
tion; this part sometimes acquires an enormous size, and as- 
sumes extraordinary and unnatural forms. M. Biett saw a 
case in which it was quadrupled in its volume. Under such 
circumstances, the scrotum is generally implicated. Finally, 
the breasts also appear to be liable to the attacks of Elephan- 
tiasis, in which case they become so much augmented in size, 
that they are obliged to be supported by bandages passed 
around the neck. According to some authors, they also be- 
come the seat of small, isolated, scirrhous tumours, which 
may ulcerate and remain incurable. 

Sensibility is seldom destroyed in the diseased parts, but the 
adjoining articulations become in many cases the seat of chro- 
nic inflammation. Adhesions take place, and the action of the 
joints being prevented, the limb is only an inert body, very 
troublesome to the patient, from its weight. 

Causes. — Elephantiasis of the Arabs is neither contagious 
nor hereditary; it attacks both men and women indifferently, 
and although most usually met with in adults, it may occur in 
young persons and children; in fact, the hardened state of the 
cellular tissue in some newly-born children, appears to apper- 
tain to this affection. It may occur in all ranks of life. It is 
endemic in the torrid zone, near the equator, and has been 
attributed to the action of the cool winds, which, in these 
burning climates, arise with the sun, and forms a strong con- 



386 ELEPHANTIASIS OF THE ARABS. 

trast with the general temperature of the day, exercising a 
great influence on the health of the inhabitants. It is rare in 
Europe. 

Elephantiasis appears, as we have said, capable of occur- 
ring without presenting any symptoms of acute inflammation 
in the lymphatic system, in which case it may arise from a 
multitude of causes, some of which are inappreciable ; at other 
times, it may be induced by the obliteration of the veins, and 
it has also been provoked by the cicatrization of an old ulcer. 

Dissection. — The skin is most generally hardened, some- 
times covered with yellowish scales or thick scabs, or it may be 
chapped, and present small, hard scales, analogous to those of 
Ichthyosis. 1st. The epidermis is very thick, chapped, and 
adherent. 2d. The mucous tissue is very distinct, and accord- 
ing to the observations of Andral, he was able to recognize the 
different layers described by Gaulthier, and afterwards by Du- 
trochet, between the epidermis and true skin. 3d. The papil- 
lary tissue is very much developed, and distinct from the der- 
mis; the papillae are elongated, enlarged, and prominent, ac- 
cording to Andral and Chevalier. 4th. The dermis is of con- 
siderable volume, and is sometimes in such a state of hyper- 
trophy, as to exceed half an inch in thickness. 5th. The cel- 
lular tissue is much developed, and sometimes contains a semi- 
fluid, gelatinous matter in its cells; but it is most generally 
hardened, slightly scirrhous, and is denser in proportion as it 
is nearer to the dermis. The muscles are usually pale, disco- 
loured, softened, and much diminished in size. Sometimes 
the veins are obliterated, and in the case reported by M. 
Bouillaud, even the vena cava itself was wanting. 

As to the general state of the rest of the system, we know 
of no other alterations that can be referred to this disease ex- 
clusively, except that glandular engorgements may be found 
in different parts of the body. 

Diagnosis. — When the disease commences by inflamma- 
tion of the lymphatic vessels, its seat may be readily deter- 
mined, but it would be difficult to decide whether it is, or is 
not a precursory symptom of Elephantiasis, for inflammation 



ELEPHANTIASIS OF THE ARABS. 387 

of this system is often met with, without its terminating in a 
hardening of the cellular tissue, or considerable swelling of the 
parts. 

But when Elephantiasis of the Arabs, whatever may be 
its real cause, whatever may be the original seat of the disease, 
presents itself with all its characters, that is, with a greater or 
less degree of a deformed and indolent swelling, accompanied 
with so great an induration that the skin does not, in some 
cases, yield to the pressure of the finger, it may be confound- 
ed with anasarca and oedema, and it is very probable that in 
certain cases this latter affection has been taken for Elephantia- 
sis; but on the one hand, the presence of certain general symp- 
toms, or the state of some of the internal organs, the softness of 
the tumour, the manner in which it is developed, the general 
state of the patient, &c. and on the other, the course of the 
disease which is entirely local, the integrity of the rest of the 
organs, the form, resistance, and hardness of the tumefied 
parts, are all characters which will serve as discriminating 
marks between the two diseases. 

Prognosis. — Elephantiasis of the Arabs is generally a 
serious disease, and is less curable where it has existed for 
any length of time, has attacked large surfaces, or where the 
skin and cellular tissue are much altered; it is also more particu- 
larly to be dreaded when it has occasioned morbid alterations of 
important parts; thus, when it supervenes on obliteration of the 
blood-vessels, it is usually a fatal affection. 

Treatment. — At the commencement, the inflammation of 
the lymphatic vessels should be combated by antiphlogistics 
and emollients; if it is very extensive, recourse must be had to 
venesection ; the application of leeches along the course of the 
inflamed vessels, will often be very successful; these are not 
to be placed immediately over the seat of the inflammation, 
but a little on each side of it; large emollient cataplasms may 
also be used. 

When the disease is in a chronic state, (the usual form in 
which it is seen,) it presents many more obstacles to a cure; 
blood-letting has been highly praised, but it is far from fulfill- 



388 ELEPHANTIASIS OP THE ARABS. 

ing the high character that has been attributed to it; general 
bleedings are of no service, and may even in some cases be 
detrimental; as to topical depletion, and especially scarifica- 
tions, so highly praised by some authors, they appear to have 
induced very different results, and we have seen patients la- 
bouring under this affection, whose limbs were seamed with 
scars from scarifications that had been practised without pro- 
ducing any amelioration in the disease. 

Blisters and caustics have also failed in a majority of cases; 
the same may be said of the mercurial preparations, which 
have been employed by some physicians; frictions, with the 
Neapolitan ointment, may be useful as a resolvent. From se- 
veral facts we have observed in the Hospital of St. Louis, and 
from the experience of many practitioners, it appears that the 
best mode of treatment consists in compression, resolving oint- 
ments, and douches of vapour. 

Compression is one of the best remedies in this complaint. 
It should be made with a bandage of two or three fingers in 
breadth, and drawn tolerably tight. It generally reduces the 
tumefaction very rapidly, and even if it does not entirely re- 
store the affected parts to their natural condition, it facilitates 
the use of other means. 

Resolving ointments may be employed with some chance 
of success; iodine appears to be the best of these preparations. 
The tumour may be rubbed with an ointment composed of a 
scruple to half a drachm of hydriodate of potash and one ounce 
of axunge. Its use is to be suspended, if the diseased parts 
should become inflamed, a frequent occurrence in this affection. 

Douches of vapour are very useful, they develope a greater 
vitality, hasten resolution, and greatly contribute to the cure; 
they should be employed for about a quarter of an hour at a 
time, and during their administration, the patient should press 
or knead the swelled parts several times. 

As to internal treatment, it is in most cases entirely nuga- 
tory, though in some cases the administration of purgatives 
has produced advantageous effects. Finally, the state of the 
skin itself may induce a multitude of modifications in the 



ELEPHANTIASIS OF THE ARABS. 389 

choice of remedies. Thus it is often the seat of Erythema, 
or it may be covered with vesicles, which occasion considera- 
ble inflammation. In such cases recourse must be had to emol- 
lient applications and simple baths. At a later period, on the 
contrary, sulphurous baths are most useful. In fact, the plan 
of treatment cannot be laid down in advance, it must arise 
from the changes and forms of the disease; which, unfortunate- 
ly, in a majority of cases, resists all curative means. 

As to amputation, which has sometimes been practised, we 
think that the cases where it would be proper are extremely 
rare, and we have even seen a patient who had been admitted 
into the hospital, for this disease, who had previously submit- 
ted to amputation, in the hopes of cure. 



50 



( 390 ) 

ORDER XIV. 

DISEASES OF THE SEBACEOUS FOLLICLES, 

IF the secretions of the skin offer a vast field of enquiry to 
the physiologist, they are also a most interesting study for 
the pathologist; but our knowledge is as yet very limited on 
this subject, and we must wait for new facts and observations 
to elucidate many obscure points, before we can attempt to 
consider these secretions in a general manner; in the mean 
time, we wish to dedicate a few lines to the history of a dis- 
ease which appears to us to be seated in the sebaceous follicles, 
the most apparent symptom of which consists in a secretion 
which is far more copious than is natural. 

This disease, which has been several times observed by M. 
Biett, has appeared to him to consist in inflammation of these 
follicles: it presents all shades, from a simple irritation induc- 
ing an augmentation of their secretion, to a violent inflamma- 
tion, giving rise to a marked alteration both in the nature and 
quantity of the secreted product. 

The follicles on the face seem to be more especially subject 
to be affected, but in many cases the disease has been more 
general, extending to the whole follicular system. When 
they are affected to a small extent, there is at first a slight ir- 
ritation which does not give rise to any change of colour in 
the skin, except that it becomes unctuous at the diseased spot; 
this irritation soon increases, as well as the secretion of the 
sebaceous matter; the fluid effused over the surface remains 
there, becomes somewhat consistent, and by a successive accu- 
mulation at last forms a kind of scaly covering of greater or less 
extent. During the first few days, this layer is soft, but little 
adherent, and easily removable, but it soon acquires greater 
tenacity, when it cannot be detached without occasioning some 
pain. Under this accidental covering, the skin is of a redder 



DISEASES OF THE SEBACEOUS FOLLICLES. 391 

colour than natural, the openings of the follicular canals, when 
examined by a magnifying glass, are found dilated and some- 
times obstructed by a solid sebaceous matter. Sometimes 
this layer is spontaneously detached, particularly during the 
summer, when the dermoid system is bathed with copious 
sweats; at other times it remains for months, especially when 
the disease is seated on the nose; when these coverings have 
lasted for some time, they assume a blackish appearance, giv- 
ing a most singular aspect to the face; this may explain the 
mistakes that have been made by inattentive observers. 

This inflammation of the follicles rarely extends to the der- 
moid tissues; that is to say, the elementary lesions already 
spoken of, are seldom seen to occur with it; nevertheless, this 
inflammation may acquire such a height as to occasion such an 
alteration in the secreted fluid, as to cause a strong analogy be- 
tween it and the sero-purulent fluid furnished by the vesicles 
of Eczema. During the time we are writing this, there is in 
the hospital an individual whose forehead is covered with a 
sebaceous crust, which participates in a certain degree in the 
characters of the scaly scabs of Eczema impetiginodes. The 
skin presents the same appearances as in simple inflammation 
of the follicles. The duration of this disease is uncertain; we 
have seen it get well in a few weeks, and at other times last 
for years. 

Causes. — It is almost peculiar to youth and adult age, never 
occurring in infancy or old age; individuals of a sanguine or lym- 
phatic temperament appear to be the most disposed to it, at least 
it has as yet never been seen except in those whose skin was 
white, fine, and naturally unctuous. It has often manifested 
itself in young and lymphatic females after delivery. M. Bi- 
ett has had for a long time under his care a woman from the 
country of about twenty-eight years of age, in whom the fol- 
licles over the whole extent of the skin, were in a state of in- 
flammation, and had given rise to a thick permanent crust; 
this person also experienced a rheumatic affection of the joints. 
In some cases, certain atmospheric changes may contribute to 
the development of inflammation in the follicles. In a iner- 



392 DISEASES OF THE SEBACEOUS FOLLICLES. 

chant of Nantes, lately attended by M. Biett, all the follicles 
of the face had suddenly inflamed from the effect of a violent 
north wind to which he had been exposed for some hours. 
This part was in a state of tension for two days, after which 
the skin became covered with an abundant unctuous secre- 
tion, which was soon transformed into a thick, adherent, 
brownish crust, which masked all the upper part of the face. 
We are not as yet acquainted with the effects that excesses 
in eating or drinking may have on the development of inflam- 
mation in these follicles. 

Diagnosis. — From the circumstance of this disease being 
so rare, and from its not having been observed with sufficient 
care, it becomes necessary to indicate the characters that are 
peculiar to it, and by which it may be distinguished from any 
other affection. 

If the follicles of the face only are affected, it will be always 
easy to distinguish their inflammation from the pustules of 
•dene, although these usually arise from an inflammation of 
the same organs. Must it be said, that inattentive practitioners 
have sometimes taken a thick, adherent, sebaceous crust, co- 
vering part of the nose, for Noli me tangere, and have 
gravely proposed cauterizations, and even excision? M. Biett 
has seen two cases of this kind which caused the greatest in- 
quietude to the patients, and which, nevertheless, were cured 
in a few weeks by very simple treatment. If the inflamed fol- 
licles are numerous, and extend over a large surface, if the 
crust that results is very consistent, thick, blackish, and so 
divided as to present the appearance of imbricated scales, it 
may be possible to confound this disease with some forms of 
Ichthyosis, but this mistake can scarcely occur, if it be recol- 
lected, that in Ichthyosis the scales are firmly attached to the 
dermis by one of their edges, that they are dry, very adhe- 
rent, and that it requires some force to detach them, all 
which never occurs in the sebaceous crust. We think it right 
to mention these differences, as such mistakes have occurred. 

Prognosis. — In the greatest number of cases of this disease, 
it presents no other inconvenience than that which results 



DISEASES OP THE SEBACEOUS FOLLICLES. 393 

from its duration; nevertheless, when all the follicles are si- 
multaneously affected, it may readily be conceived that the 
disease is not without danger. 

Treatment. — When the diseased follicles are but few in 
number, and occupy but a small surface, a cure may be more 
readily and promptly expected than when the contrary is the 
case. M. Biett has several times seen follicular irritations 
yield in a few weeks to the application of vapour douches to 
the affected part for fifteen or twenty minutes at a time. Un- 
der the influence of this efficacious remedy the sebaceous crust 
softens and is detached with great ease ; that which succeeds 
is generally less consistent, and is often spontaneously disen- 
gaged. Lotions with narcotic infusions in the first instance, 
and afterwards rendered styptic by the addition of sulphate of 
alumine or some of the vegetable acids, also contribute to re- 
store these parts to their natural condition. In some cases it 
is useful to aid the action of these local means by some mild 
revulsants used internally, but great caution must be employ- 
ed when the disease is general ; in such case the gastrointes- 
tinal mucous membrane often presents traces of irritation, or 
at least, according to the observations of M. Biett, the use of 
tonics and purgatives is generally followed by a sense of heat 
at the epigastrium or other parts of the intestinal canal. In 
these severe cases, gelatinous or mucilaginous baths, slight fric- 
tions repeated every day, will suffice to detach the sebaceous 
crust, and at a more advanced stage, alkaline baths, slightly 
stimulating frictions, or vapour baths, if the state of the pa- 
tient does not contraindicate their use. These means are to be 
aided by a regulated regimen proportioned to the condition of 
the system, a milk diet, and by all those hygienic plans of 
treatment which will concur in restoring the general health. 



( 394 ) 

ORDER XV. 

KELOID E. 

Cancroide. 

THE forms of diseases of the skin are so numerous and 
diversified, that almost every pathologist who has specially 
attended to them has described some new varieties. The 
Keloide was noticed first by Alibert, under the name of Can- 
croide, which he afterwards changed to its present denomina- 
tion. 

This disease appears to be rather rare, since it has not been 
seen by many of the late authors on cutaneous affections: Bate- 
man even doubts its existence, and instead of confessing with 
candour that he had never seen it, he seems to infer that the 
French author of the magnificent work on diseases of the skin 
has made some mistake. But Keloide really does occur, al- 
though it has as yet been observed but in a few individuals ; 
its characters are so well marked that it may not only be in- 
stantly recognised, but it would be almost impossible to con- 
found it with other diseases. 

It manifests itself by a slight tumefaction of the skin, which 
soon extends in size and prominence, and forms small, flat 
tumours, which although often irregular, are generally of an 
oval shape with a central depression. At other times they 
may be elongated, angular and shining; the epidermis which 
covers them is thin and slightly wrinkled, so as to give it the 
appearance of the cicatrix of a burn ; they are hard and resist- 
ing to the touch; their colour is sometimes of a deep red, and 
at others of a pale rose colour. This colouring however dif- 
fers according to the temperature and state of the patient. 
These flat tumours are about one or two lines in height; this 
is greater at their circumfefence than at their centre. 



KELOIDE. 395 

In the greatest number of cases the disease forms but one 
patch, whilst in some instances there are many; M. Biett has 
seen a young lady, whose case he communicated to Alibert, 
who presented eight small, flat tumours on the neck and late- 
ral part of the breast. Very lately the same pathologist has 
observed two of these tumours on another patient from the 
environs of Caen. 

The Keloide may acquire an extent of one and a half to two 
inches in its greatest diameter; it may also occur of only a few 
lines in breadth, particularly where it is multiplied. 

In some patients it occasions great pain and throbbing, which 
are more apparent during atmospherical changes, and painful 
tinglings after meals; at the same time it must be allowed that in 
some patients, none of these symptoms manifest themselves; 
the small tumours arising and increasing without being accom- 
panied with any pain. 

When Keloide is left to itself, it makes very slow progress ; 
it rarely terminates by ulceration, and the cases in which this 
has been said to have taken place, are not sufficiently verified. 
In some cases, as has been remarked by Alibert, it may dimi- 
nish and disappear, leaving a white and firm cicatrix. The 
most common seat of Keloide is on the anterior part of the 
breast. At the same time, it often appears on the neck or 
arms. 

Causes. — Keloide has been too rarely observed for any very 
exact knowledge to have been acquired as to its etiology. In 
some persons who were attacked with it, the disease had com- 
menced without any kind of disorder, either local or general, 
except a slight smarting. In some cases, it appeared to have 
arisen from some external cause. In a lady, w r hose case is 
detailed by Alibert, the Keloide manifested itself after a deep 
scratch she had received on the breast. 

As yet, this disease has never been seen in infancy; it has al- 
most always occurred in young persons approaching adult age. 
Alibert believes that the Keloide is more common among fe- 
males than males, but in comparing the observations made by 
Biett, and those given by Alibert, in his great work, it will be 



396 KELOIDE. 

found that in nine patients affected with this disease, that there 
were four men and five women; hence it is apparent that it can- 
not be said to be more frequent in one sex than in the other. 

Diagnosis. — Keloide ought to be sedulously distinguished 
from the cancerous affections, with which, however, it has 
but little analogy. In a majority of cases, cancers of the skin 
form round, prominent, livid tubercles, ulcerating at their 
summit, and environed with dilated veins distributed over a 
hard and withered skin. The neighbouring glands are en- 
gorged, and sometimes acquire an enormous size. The Ke- 
loide, especially when it is seated on the anterior part of the 
breast, consists in the greatest number of cases, of a prominent, 
flattened spot, elevated at its edges, resisting to the touch, and 
in most cases, occurring on healthy skin, which retains its natu- 
ral colour, &c. 

The Keloide can never be confounded with syphilitic tu- 
bercles. These are always in great numbers, and assembled 
in groups; they are rounded at their summits, of a coppery or 
livid colour, and intermingled in a plurality of instances with 
cicatrices, besides which, they are generally accompanied with 
general symptoms of the constitutional affection. 

When the Keloide consists of numerous small tumours, they 
are separated by intervals of sound skin ; they are of a rose 
colour, are sometimes square, and at others of a triangular 
form, but never assume the rounded form peculiar to the sy- 
philitic eruptions. 

This disease can scarcely be mistaken for sanguineous 
tumours. In fact, these latter form vascular vegetations; 
they are scattered or disposed in groups, and are at first 
on a level with the skin, but gradually enlarge and assume 
the form of true fungous tumours. Neither have the erectile 
tumours of Dupuytren any analogy with the Keloide; they 
are brownish, and generally granulated at their surface ; their 
base is large, and sometimes profoundly implanted in the der- 
moid tissue; they are soft to the touch, whilst the Keloide is 
firm. They often present movements isochronous to those of 
the arterial pulsations. Nothing like this takes place in Keloide 



KELOIDE. 397 

Prognosis. — The Keloide is never a serious disease; that 
is to say, it never is attended with danger, and if in the case 
reported by Alibert, the tumour eventually assumed a threat- 
ening appearance, it was rather owing to the remedies em- 
ployed than to its natural progress. In the majority of indi- 
viduals in whom this eruption has been observed, the state of 
health was never affected. 

Treatment. — The therapeutic means to be used, are the 
same as have been indicated by Alibert. Surgical treatment, 
as extirpation and cauterization, are never advantageous. Ap- 
plications of a different nature have also failed in most cases. 
Sulphurous douches have sometimes appeared to have dimi- 
nished the hardness of these small tumours. Frictions with 
the hydroidate of potash may be used with some chance of 
success. If any favourable opportunity should present itself, 
M. Biett intends to give it a fair trial. 



51 



INDEX. 



Acne .... Page 


181 


Erythema - - - ] 


simplex - 


183 


papulatum 


indurata - - - 


184 


tuberculatum 


rosacea - 


186 


nodosum 


Albinism .... 


310 


fugax - 


Bullar diseases 


120 


lseve 


Bronze colour of skin - 


299 


Exanthematous diseases - 


Barbadoes leg - 


381 


Febris miliaris 


Cancroide, see Keloide 


394 


Fievre orttie 


Chicken-pox, see Varicella 


72 


Frambcesia - 


Couperose, see Acne 


181 


Freckles - 


Cow-pox, see Vaccinia 


158 


Gutta rosea - 


Crusta lactea, see Porrigo 


214 


Herpes - 


Dartre erythemoide 


27 


phlyctenodes 


Dartre squammeuse humide - 


78 


labialis - 


orbiculaire - 


258 


preputialis - 


centrifuge 


259 


zoster 


pustuleuse couperose 
miliaire 


182 


circinnatus 


ib. 


iris 


mentagre 


191 


exedens 


phlyctenoide 


124 


Ichthyosis 


confluent e 


95 


Impetigo 


en zone 


101 


figurata 


crustacee 


172 


scabida 


fiavescente 


ib. 


sparsa - 


furfur ac^e arrondie 


243 


erysipetalodes - 


volante 


265 


Intertrigo ... 


rongeante 


313 


Itch .... 


Ecthyma - 


85 


Keloide .... 


infantile 


166 


Lentigo 


cachecticum 


168 


Lepra .... 


syphilitica 


342 


nigricans 


Eczema .... 


78 


Lepre tuberculeuse 


simplex 


ib. 


elephantine 


rub rum 


79 


Lichen - 


impetiginodes 


81 


simplex 


chronic 


82 


pilaris 


solare .... 


85 


lividus 


Elephantiasis grsecorum 


277 


circumscriptus 


Elephantiasis of the Arabs 


381 


gyratus 


Ephelis .... 


304 


urticatus - 


Ephelides hepatiques 


ib. 


strophulus - 


lentiforme 


302 


agrius 


Erysipelas - 


32 


syphilitique - 


erraticum 


33 


Maculae .... 


cedematodes 


34 


Measles - 


phlegmonodes 


ib. 


Mentagra 



Page 



27 

28 

ib. 

ib. 

29 

ib. 

25 

70 

61 

285 

302 

181 

94 

95 

98 

99 

101 

106 

109 

313 

268 

172 

ib. 

175 

ib. 

176 

29 

110 

394 

302 

243 

349 

277 

381 

225 

ib. 

226 

ib. 

ib. 

ib. 

227 

ib. 

228 

347 

295 

45 

191 



400 



INDEX. 



Miliaria 


Page 70 


Rupia simplex 


Page 130 


rubra 


- 71 


prominens 




131 


alba - 


ib. 


escharotica - 


. 


132 


Moles - 


- 309 


Scabies .... 




110 


Molluscum - 


290 


Scarlatina 


. 


52 


Naevi materni - 


- 308 


simplex 




53 


Xsevi - 


ib. 


anginosa 


- 


ib. 


Nettle-rash 


■ 61 


maligna 


. 


54 


Papular diseases - 


223 


Scaly diseases 


. 


241 


Pellagra - - - - 


- 332 


Sebaceous follicles, diseases of 


390 


Pemphigus . 


122 


Shingles 


- 


101 


acute - 


- 123 


Small-pox ... 


- 


138 


chronic - 


124 


Spili .... 




308 


gangrenosa 


132 


Strophulus intertinctus 


- 


227 


Pityriasis - 


- 265 


confertus 


- 


ib. 


versicolor - 


304 


volaticus - 


. 


ib. 


Pian - 


- 285 


albidus 


. 


ib. 


Pompholix solitarius 


124 


candidus 


- 


ib. 


diutinus - 


- ib. 


Swine-pdx - 


- 


72 


pruriginosus 


127 


Sudamina - 


- 


Jn 


Porcelaine 


- 61 


Syphilitic eruptions 


- 


336 


Porrigo ... 


197 


exanthematous - 


- 


338 


favosa 


- 202 


vesicular 


- 


339 


lupinosa, Will. - 


ib. 


pustular - 


- 


341 


scutulata 


- 210 


tubercular 


- 


344 


larvalis 


214 


papular 


- 


347 


favosa, Will. - 


- ib. 


scaly 


- 


349 


granulata 


220 


Syphilide pustuleuse ortiee 


- 


338 


furfurans 


- 94 


miliaire 


- 


341 


Prurigo 


233 


lenticulaire 


342 


mitis 


- 234 


en grappe 


344 


formicans - 


ib. 


merisee 


- 


ib. 


senilis 


- 237 


Taches de rousseur 


- 


302 


Psoriasis 


255 


Teigne amiantacee 


- 


93 


guttata 


- ib. 


furfur acie 


- 


ib. 


diffusa 


256 


muqueuse 


175 


. 214 


infantilis, Will. 


- 257 


faveuse 


- 


202 


inveterata 


ib. 


annulaire 


- 


210 


gyrata - 


- 258 


granule - 


- 


220 


ophthalmica 


ib. 1 


Tinea - 


- 


197 


labialis 


- 259 j 


granulata 


- 


220 


preputials 


■ft. 


Tubercular diseases - 


- 


275 


scrotalis 


- ib. \ 


Urticaria - 


- 


61 


palmaria - 


ib. 


febrilis - 


. - 


65 


Psoride pustuleuse 


- 110 


evanida 


- 


64 


papuleuse 


233 


subcutanea 


- 


65 


Purpura - 


- 368 


tuberosa 


- 


ib. 


simplex 


369 


conferta 


- 


63 


hemorrhagica 


- 371 


Vaccinia 


- 


158 


Pustular Diseases - 


135 


Varicella -'-■".- 


- 


72 


Roseola - 


- 42 


Variola 


- 


138 


aestiva 


- 43 | 


Varioloid ... 


- 


150 


autumn alis 


- ib. 


Vesicular diseases 


- 


68 


annulata 


ib. 


Vitiligo ---.-.- 


- 


312 


Ptoseole syphilitique - 


- 338 


Yaws - - - - 


- 


285 


Rubeola 


45 


Zona .... 


- 


101 


Rupia .... 


- 130 









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